Let’s ditch the guilt and get realistic on breastfeeding

Many Irish women mix breastfeeding with formula and while health professionals advise exclusive breastfeeding for the early days to establish supply, once this is up and running, do you still get the full benefits of breastfeeding if a baby gets a nightly bottle of formula?

Ten percent of mothers leaving Irish maternity hospitals are already using mixed feeding (23 percent for multiple births) with less than half exclusively breastfeeding, according to CSO perinatal statistics.

Separate research from 2015 shows nearly equal numbers of women in Ireland using mixed feeding and exclusive breastfeeding at 3-4 months with 15 per cent of breastfeeding mums also giving formula, while 19 percent were exclusively breastfeeding.

With medical studies showing a link between breastfeeding and night-time wakings, many are supplementing with a bottle at night to give everyone a longer stretch of sleep and, according to consultant neonatologist and paediatrician Afif EL Khuffash, this will not make a big difference to supply once breastfeeding is established.

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“In the early days of breastfeeding, milk production is regulated by hormones so constant feeding is essential to get supply going. Once breastfeeding is established, some may find their supply falls a little if they supplement with a bottle of formula at night, but this is not a problem as the formula will replace this, and not all mothers will experience this drop in supply,” he says.

Prof EL Khuffash, who is also a lactation specialist and is based at the Rotunda Hospital in Dublin, says the idea of exclusive breastfeeding can be quite overwhelming for women already exhausted by childbirth and there can be a guilt around giving formula for breastfeeding mothers which is not helpful.

So, once breastfeeding supply has been established is there any harm in giving a nightly bottle of formula to give mum a break?

“Harm is the wrong word. I really don’t like to use that term. Mums can feel very guilty but there is no evidence that one bottle makes any difference. When you are breastfeeding the make-up of bacteria in the baby’s intestine is different from formula-fed babies and if you are breastfeeding then you are still colonised with the good bacteria, regardless if a nightly bottle of formula is introduced,” he says.

Big drop

Prof EL Khuffash points out that health professionals want to support mothers with any breastfeeding they want to do and acknowledges that the term “exclusive breastfeeding” can bring a lot along with it and that if the option of a little flexibility after a few weeks was communicated to new mums this may encourage more to initiate breastfeeding and keep it up for longer.

“If mothers can feel they can safely give a bottle at night once breastfeeding is established, it may help to improve the breastfeeding relationship overall by giving more time and freedom to the mother, and this is really no problem for the baby’s health,’’ he says.

He advises that if a woman does notice a big drop in supply from skipping a feed she may decide to pump for around 10 minutes or so and could freeze the milk to enable future flexibility.

Prof EL Khuffash specialises in looking after premature babies and did point out that regarding breast milk and preterm infants the evidence is strong with some benefits including lower incidence of necrotising enterocolitis (a severe gut infection), lower incidence of chronic lung disease and better immunity and feeding tolerance.

He says that while breastfeeding is the optimum way to feed your baby, it is wrong to say that formula is harmful in any way as there is no evidence to back this up and more honesty is needed around Ireland’s low rates of breastfeeding.

Forget the shame

Economist Emily Oster of Brown University in Providence, Rhode Island, has read hundreds of medical studies while researching her data-driven guide to parenting, Crib Sheet, and she agrees that if mothers have the flexibility of supplementing this may encourage longer periods of breastfeeding.

“In general, the benefits of breastfeeding at all are smaller than many people claim. But beyond this there is simply no evidence that using some formula in addition to breastmilk is problematic. And, indeed, supplementation can actually improve breastfeeding success if it makes it easier to continue,” she says.

After examining the body of research on breastfeeding, Prof Oster came to the conclusion that the most definite benefits of breastfeeding seemed to be a reduced risk of breast cancer for the mother, improved digestion for the baby in the first year and less occurrence of rashes.

While breastfeeding was important for preterm babies, the other long-term benefits of higher IQ and lower levels of obesity had no hard evidence to back them up.

She says this is because most studies are biased by the fact that women who breastfeed are typically different from those who do not – in most developed countries they are richer and better educated – and having more resources and education is going to lead to better outcomes for children, which makes the causation of breastfeeding leading to these better outcomes trickier to prove.

Prof Oster points to one study in particular that controlled for the mother’s IQ, which showed that when there was a sibling who was breastfed and another one who was not there was almost zero difference in their IQ (0.02 points). This contrasts to the headline figure of an improved 4 per cent IQ difference between breastfed and formula-fed babies that other studies claim.

Less idealistic view needed

It has been well publicised that Ireland continues to rank among the lowest breastfeeding initiation rates in the EU – the WHO recommends exclusive breastfeeding for six months but hardly any Irish women achieve this (2.8 per cent).

Breastfeeding was discouraged in the 1970s as it was thought formula-fed babies gained weight faster and although rates are climbing they are slow to improve. Only 56 percent of Irish women initiate breastfeeding at birth and over half have given up in the first two weeks.

The truth is that the idea of exclusive breastfeeding can be overwhelming and perhaps more women would push themselves to keep going if the narrative was opened up and they were told that if they do decide to introduce one daily bottle after a few weeks that this is not going to make much difference.

Sleep deprivation is tricky and makes it harder to function or be a good parent and if you are using a nightly bottle to give yourself some shut eye you really don’t need to feel guilty about it.