Part Two of a Conversation with
Dr. Amna Husain, MD, IBCLC & Callan, Editor
Dr. Amna Husain is a Board-Certified Pediatrician and an Internationally Board-Certified Lactation Consultant (IBCLC) who owns a concierge pediatric practice.
In part two of our interview series, she and Motherhood Editor Callan, who was nursing her 15-month-old daughter, discuss ways to feed baby, how to choose a baby formula, and introducing a bottle to baby.
Callan: What are your thoughts on the whole idea that breast is best versus fed is best? And should it be a versus? Or is it just: feed your baby and do your best.
Dr. Amna: That's a good question. I find that both of them can be, I guess, comforting to hear, but also off-putting to hear. I know that sounds like a really backwards thing to say, but I'll tell you my personal experience. I was a pediatric resident and I thought, hey, I got this. I know what breastfeeding is. And like I said, it's a relationship. So around seven weeks of life, my daughter refused to really latch, and I had to go to exclusive pumping. And I kept thinking: breast is best, breast is best. And when I went back to work, it really took a toll on my mental health and my sanity for a little while. And I think it kind of interfered, just like I said, with sort of my relationship with her. And I had to take a step back and think: OK, I always thought breast is best, but maybe just feeding the baby is good. And it doesn't matter if all of it is breast milk or some of it is breast milk. I'll do what I can. So, I let moms kind of interpret that for what it is. And I think it can mean different things to you at different times in your life. And that's OK. I certainly don't think I'm alone here. When some women go back to work, they do have a very difficult time keeping up with production and keeping up with pumping because it's really not the same nurturing thing. You can’t bond with your pump. So, I completely understand. I'm kind of team: what does mom and what does the baby want? If the baby is still latching really well and feeding really well for you, that's OK to keep breastfeeding for however that you'd like to. If the baby is similar to mine and it does not want to latch, it's OK to feed the baby with pumped breast milk or feed the baby with formula. The important thing is that you and the baby are both healthy and thriving.
Callan: And can you share why some women or babies may not be able to breastfeed long term or at all, and how you would coach these women to not feel guilty about taking the bottle route?
Dr. Amna: So the first thing I want to set clear is, it's not something about you being a good mom versus a bad mom. Trust me, as a pediatrician poster child, and this is before I was a lactation consultant, I had so much guilt about ever giving my baby formula. And I even knew that formula was OK for a baby. It’s OK to move out of that mindset about whether you're a “good mom” or you're a “bad mom.” This has nothing to do with that.
There's a lot of things that can really affect breast milk and production. Stress levels is one of them. Going back to work, different changes in environment, going from the home and being with the baby all the time to being in a workplace, or maybe you're going through something else right now. Maybe you are moving homes or moving states or moving through different careers at the time, so it's a different change in environment. I think another thing to point out is there's not just a difference with what mom is experiencing, but also the child.
Some babies might nurse till 15 months, 18 months, 24 months, three years, four years of age. Great. I think that's a really wonderful relationship to nurture and to continue, if you can. Some babies on their own are ready to pull off close to 10 months, 11 months of age, maybe even sooner sometimes. Of course, when it's that early, we can't really switch them over to a dairy type of milk, like a cow's milk, or anything at that time. But it's really dependent on the child. And one really important thing I want to point out is it's also just variable from pregnancy to pregnancy. I've had some women who were great producers maybe in their first pregnancy and in their second pregnancy not so much or vice versa. For one child, they didn't have a great experience and they had low supply. And then for the second child, there was a big change. So, it can vary from pregnancy to pregnancy, child to child, and even from left to right breast. I think many women are surprised to hear there's always a super breast that might pump more or feed more or have a greater capacity.
Callan: I had one, a "good boob" and a "bad boob" I liked to call it. Very evident when you're pumping like, oh, no wonder the baby likes that side better.
Dr. Amna: I know we all have that one. And you know what? Probably not evidence based at all, but I'm usually finding that it's right over the left. I don't know, I should do a study.
Callan: Interesting! So, are there some cases where a baby or a mom may not actually be able to nurse based on physical issues?
Dr. Amna: Absolutely. I'm glad you asked this, because this is kind of where medical history and knowing anatomy really comes into the picture. There are certain situations where women have had a breast augmentation done and you can actually still breastfeed. Or breast reduction where you can still breastfeed. But it really depends on where the tissue was taken from when it comes to breast reduction, and how the incision is made with breast augmentation. People are surprised to hear that you can still breastfeed if you had breast augmentation surgery, but it really depends on how the incision is made. So, if you have concerns about that, no matter what stage of life you're in right now, let your plastic surgeon know because they're usually able to address those. And now I think, especially as more and more women are comfortable talking about breastfeeding and breastfeeding in public and bringing up those concerns openly, plastic surgeons and other surgical fields are becoming more and more conscious of it. Certainly, surgeons who operate for breast cancer are definitely conserving as much breast tissue as they can. So those are definitely some things that I think about for some women, that depending on how the incision was made, you may not be able to have as high of a supply.
Now, when it comes to children, it actually depends on the anatomy of the child, too. It depends on how much tone they have. One of the biggest calorie-burning exercises that children do initially is eating and I talk about that a lot with parents. They always ask, why do they go to sleep after or why do they sleep while nursing? And it's actually pretty hard. That tongue is doing a lot of work and that jaw is doing a lot of work. And that action burns a lot of calories even though they're taking it in. So, they do fall asleep. They do get tired. Now think about that. You need to really have appropriate muscle and jaw control to be able to take the milk and move it to the back of the throat. Some babies may have a cleft lip or a cleft palate, and they may not be able to do that. Some babies are born with a little less tone. We call it hypotonia, which can happen sometimes. And they just may not have enough strength to really hold their head up or hold their body up and be able to have that vigorous swallow/suck pattern. So those are things that a pediatrician is able to step in and take a look at. And it's not something, especially the hypotonia, that's going to be just grossly evident to you. You kind of have to do a full body exam. So, there's many, many different reasons why.
Callan: When might a mother consider supplementing with formula?
Dr. Amna: One thing that I really like to focus on when it comes to supply is the most objective thing: the baby not gaining weight. I say that because parents and mothers, they often rely on nonobjective findings like: My breasts might not be leaking as much as they were initially. Does that mean my supply is gone down? That really just means your breasts have really accommodated how much milk is being produced, right? It's a big deal and for the first two weeks your breasts are like, what's going on? And there's all this milk production and you're so sensitive to the baby's let down and cry reflex. Just because you don't feel your breast leaking doesn't mean your supply is slowing down. It's just that your breasts have really begun to accommodate that and so have your ductules. Some women are worried that their supply is low because the baby is fussy, fussy during the day or in the evening. Unfortunately, babies fuss a lot in the evening, it's that witching hour. But that doesn't mean that your supply is just low. Sometimes, absolutely, in the evenings your breasts might be producing lesser amounts, but that's not to say that your supply is low in general.
Other things that moms sometimes fixate on, they worry about frequent nursing. So unfortunately, frequent nursing and cluster nursing is part of the game. So that's not necessarily because you can have a supply issue. Sometimes when there's bottle preference or use of nipple shields, that can be cause for moms to worry about supply issues. But one of the first things I always say to think about is: is the baby gaining weight? It's not just how your breasts are leaking or the way your breast feels after. Is the baby gaining weight? So at a lactation consultant appointment, we can take a look at the baby, we can assess the latch and then see you breastfeed. We assess for transfer of milk too by doing a weighted feed. We call it a weight before in a weight after, and we can see how milk's been transferred. And that's one of the first ways we can know that, OK, baby is getting milk. Is the baby gaining weight thereafter?
Callan: So if you do decide to supplement with formula, are there specific things you should look for when you're selecting a formula? Are they all kind of equal?
Dr. Amna: Let's talk about this, because I used to find formula incredibly confusing while I was in my residency for pediatrics. And I don't think it really clicked to me until it all came together, and I was forced to learn it as a mom. So, first of all, there's three big companies, so Enfamil, Similac, and Gerber, and there's some European countries and organic companies. Earth's Best is another one, but those are the three big ones. If you go to any grocery store, you'll probably see something like Similac, Enfamil or Gerber. Now, within those, you're going to find what we call sort of your regular formula for any baby, and they'll all have some different strands of each one. Some of them will have something for the colicky baby, some of them will have something for the acid reflux baby. Some of them might have something that says we add DHA and ARA, fatty acids for the baby's brain. But those are the three typical formulas. And then they each have their subset of those particular things that we just talked about.
One thing to know is before any formula hits the market, they are all approved by the FDA. So I always recommend when parents are switching around formulas, just kind of let your pediatrician know, too, because sometimes switching around formulas isn't the best thing for you or the baby, because it does take a little bit of adjusting and getting used to. And sometimes it just causes extra stress if you're going between one formula or the other. Not to mention these formulas can be kind of expensive. Now, let's talk about ingredients of formulas, because I know some parents may turn them around, they're like, wow, there's so many ingredients. But you're right, because there are things to kind of preserve the formula on the shelf. They all have expiration dates. These aren't things that are OK for years and years and years. They all have expiration dates as they should. So, you might see things like lecithin or carrageenan or monoglycerides or diglycerides. They're all there to preserve the shelf life. And again, you'll see very similar things that would also be in breast milk. Sugars like lactose.
So when it comes to formulas, usually I tell parents, unless your pediatrician says otherwise, it's OK to just start with the regular old Similac, Enfamil, or Gerber. The regular old formula. And then if things get complicated, let's say your child has a cow's milk protein allergy and they can't tolerate lactose, we can switch things around and go to what we call partially hydrolyzed formula. And all that means is it breaks the proteins down just slightly to make it a little bit more easily digestible for the baby. I don't really switch around things without talking to the pediatrician, though, because as these formulas get more advanced, the cost does increase. So sometimes your pediatrician can help you out with coupons, sometimes even when it's really a need for something more advanced, we can actually even give you a prescription so we can get it covered for you if needed. But we need to know first if this is something that you're doing at home. Again, there's situations where babies have severe acid reflux and we move to something called extensively hydrolyzed and then those proteins, I like to think they're broken down even more so to make it even easier for the baby to eat. So those are kind of the three ranges that we see, all three companies, Similac, Enfamil and Gerber falling into. If I haven't confused you enough already, that's the way I kind of try to categorize things.
And so, as you can imagine, when I first walk to a formula shelf and I had no idea what I was doing, I was so confused. But now when I kind of keep that in the back of my head and think about the companies, and that each company makes basically the same thing, but names it a little differently, it makes me feel a little better. Now, you might see other things like ARA or DHA added in. So those are polyunsaturated fatty acids. So that is important when it comes to neuronal development. Now, some formula companies have started adding this in, which is totally fine. It won't necessarily give your baby an extra benefit or your baby won't be at a loss if you don't choose that formula. But I just want to know that that's basically what it means. So, when you see something advertised that way, they say it's to help with neuronal development. Absolutely. Polyunsaturated fatty acids can, but they can also get that from mom's diet if you're nursing as well. So that's kind of the 411 a little bit on formulas, but I let parents know that just talk to your pediatrician beforehand because we can probably help guide you when it comes to these decisions.
Callan: I just picked a formula that a coworker said she used and liked because there's so many. She said her baby's poop didn't change from breastfeeding to introducing the formula. I was like, that seems like a good sign, I'll just use that.
Dr. Amna: You know, there's some subtle small differences, like what type of protein. Formulas mostly have casein protein and breast milk mostly has whey protein in it. But there's just subtle differences for the most part. I tell parents when you overthink it and you switch around too much, you're just causing more stress on yourself. And who needs that as a parent?
Callan: Bottle feeding, any tips on getting a breastfed baby to take a bottle? When you should introduce the bottle? What if the baby refuses? I had a really difficult time with this with my daughter. It took about a month to finally get her to take a bottle and it was torture.
Dr. Amna: I have a couple of tips, actually. First of all, it's your choice when to introduce a bottle. Some families choose to introduce a bottle the first day or the first week. And that's fine. And you don't have to necessarily be married to the bottle that you introduced the first week either. But things are changing so much in the first two weeks. You're basically always bring your baby to breast and then sometimes you randomly, let's say, give a bottle. Don't worry about which nipple you used. We can always change things around later. Now, when you choose to introduce the bottle can vary. Let's say you're a mom who's going back to work and you've really not introduced bottle at all. I usually recommend starting to introduce the bottle about four weeks before. So just like you said, a month. Now, one thing you can do is have mom give the bottle and see how that goes. Sometimes babies are like, "Why is my mom giving me the bottle? I do not want this. I want the nipple." So, it can be really difficult. Let's first start off with the mom giving it and see how it goes. Next, we can progress to another caregiver. It could be grandma who’s in the house. It can be the nanny, the babysitter. Dad can give the bottle. Now, sometimes if mom's in the kitchen or in the right in the same room, the baby has the same feeling like, what is this? My mom sitting right here, why would I want the bottle? So we might have to do something else. Maybe the mom goes upstairs. I've even had patients where the mom actually has to kind of leave the house to allow the baby to get really used to the bottle. And I know that sounds drastic and severe, but sometimes you actually may have to do that. Think about it if your child was a toddler and they were clingy with their mom and mom says, "OK, mommy has to go get ready for work." And they don't want to be with the nanny. They just want mommy. Sometimes it takes the mom leaving the house for the child to finally get OK. I'm totally fine with the nanny. They were just having an issue of being a little difficult. It's kind of exactly the same concept. So when it comes to bottle preference, you might see this happen right again when your child is a toddler, they're clinging on your leg and they don't want to leave. So that's one of the things I recommend. So try introducing it about a month before you really want the bottle to be regularly introduced.
Now, what type of bottle is also important. So one thing I emphasize and I kind of have a piece of paper or I draw right on the exam room table with the parent is there's a really big difference between the standard bottle nipple that we get in the hospital with the supplemental formula and basically the shape of a breast. And a lot of bottle companies have picked up on this and gotten really smart about it. So rather than your typical nipple, that's almost got like a very small circular base and has a long nipple that sticks out, I mostly try to advise parents to stick to broad bases where they have almost a shorter nipple and it kind of emulates more of the breast. First of all, that really helps when it comes to bottle preference versus nipple preference. Let's pick something that's a little similar. It really does help. Now, the second thing they also say is start choosing paced bottle feedings and do this early on. So paced bottle feeding, and I always refer families to a video that I like to use. It's on YouTube and it's super cheesy. It was probably made in the nineties or something, but it's a five-minute video and the woman really explains what is paced bottle feeding. And we talk about it together when we have our consultation as well and when parents are going back to work. Basically, what you're trying to do is rather than allowing baby to basically gulp the milk as fast as they can, that's not the way the breast works at all. The baby has to suck to get the milk out and it can take at least fifteen minutes to do so. Try to emulate the same with the bottle. You're really not turning it completely, 85 degrees or 90 degrees, but tilting it just a little bit and the baby has to suck for them to get the milk out. Now your bottle feed may take longer than the typical five minutes, but that's actually what we call paced bottle feeding. And I found that to be one of my favorite tricks to keep sort of in my back pocket. And it really does help. It kind of does allow the baby to take their time over the course of a meal so that they can realize that, OK, I'm full and I don't want any more. Think about it. It's just like when we sit down at the table and we shove our mouth full of food instead, if we take a minute and chew our food, put our fork down and have a little bit of a conversation, swallow, drink something. All of a sudden, we realize at the end of our meal we've paced ourselves and we may not be as uncomfortable and it's exactly the same thing. And you're emulating the way the breast works too. So those two are some of my biggest tips when it comes to a bottle.
Callan: Awesome. Yeah, I found I had to switch to the Nanobébé bottle, I don't know if you've ever seen that. It literally looks like a boob. It was the only bottle that my daughter would take.
Dr. Amna: I didn't have a problem with bottles, but sippy cups. I could have owned a sippy cup store because I think I had so many sippy cups that I tried and I was like, I don't know what to do here. Amazon probably thinks I am a sippy cup.
Callan: Yeah, my daughter didn't like pacifiers, it was really hard with the bottle. She didn't like sippy cups. We use the cups that don't have a spout which she'll drink out of. But I think she just doesn't like the silicone feeling in her mouth.
Dr. Amna: OK, so pacifiers I think get a really bad rap as well. And I think pacifiers can actually have a really helpful place. So certainly, as a lactation consultant and as a pediatrician, I say just try to stay away from pacifiers for about the first three to four weeks. And the reason we say that is when a baby's showing you signs of hunger, rooting and sucking and gnawing on their fingers, if you put a pacifier in their mouth, it does calm them. But it's not allowing your breasts to get that signal. Let's say you put them at the breast, they start sucking, they start emptying the breast, your breasts get the signal to produce more milk. That is so important, especially in the beginning. I talked about recently how the first two or three weeks is just kind of like a big, fuzzy, gray area where you just feel like you're constantly nursing the baby. We kind of do need that, though. We do need you to sort of autoregulate to the baby and the baby to autoregulate to the mom and understand the relationship. So, I do think, though, that pacifiers can be really useful after the first three to four weeks of life. When we say breastfeeding has been a little bit more established, when you feel like the latch is a little better and the baby is gaining weight nicely. They can be actually helpful and beneficial and lessen the risk of SIDS. So that's really important, too. I think those are things that people don't even know about pacifiers.
When it comes to a pacifier, I find often that the ones the hospital give out are really not the same shape as the nipple, and it's a little harder to compress down on. It can cause some nipple confusion, especially if introduced early. My favorite brands are the ones that are orthodontic friendly. You'll see that the tip of the pacifier is just slightly curved and it's a little bit of a softer nipple too. I think those are just a little bit more friendly for children. And as a pediatrician, I'm thinking way beyond even the first year of life, when we try to get them off of pacifiers after the first year of life. So, if you can use the orthodontic friendly brands, we can keep a friendly space for their teeth as they're coming in.
