Issue 132, September/October 2005
By Paul M. Fleiss with Frederick M. Hodges

Because young American women today grow up in a culture that bears the marks of decades of an officially orchestrated anti-breastfeeding campaign, to many of them breastfeeding remains strange and mildly disgusting. In earlier centuries, when families were larger, and before the relentless marketing of formula feeding, there was no mystery about breastfeeding-children grew up seeing their own mothers breastfeed. A young girl could watch as her newborn sibling latched on to her mother's breast, and could observe how the mother would switch the nursling from one breast to the other. She unconsciously noted the frequency of feedings. In short, girls received years of valuable lessons in how to be a good mammal without ever having to read a book or take a class in the subject.

Today girls seldom have the opportunity to see their mothers breastfeed younger siblings, and boys, too, are denied this important lesson. I am convinced that returning our society to its breastfeeding-friendly roots depends as much on teaching little boys about the naturalness, desirability, and superiority of breastfeeding as it does on teaching little girls those values. Seeing women breastfeed in a variety of settings will benefit boys as well as girls. Those boys will grow up to be better husbands and fathers.

Without the support of an informed and courageous husband, young mothers who want to breastfeed may find their efforts undermined. Some men may object to their wives breastfeeding out of "breast envy." They feel left out and useless because the mother seems to be doing all the parenting. Naturally, there is much that fathers can do to help with the baby. A baby has a vital need for his father to hold and caress him, sleep and walk with him, bathe him and change his diapers, sing to him, and countless other demonstrations of fatherly love and devotion. An observant and thoughtful wife will encourage her husband to share in these tasks, whether or not he suffers from breast envy. After all, a newborn baby is more work than anyone who has not had one can imagine.

In addition to caring directly for the baby, fathers have another very important role to play: serving the mother. In the first few weeks after birth, all of a mother's energies are devoted to her newborn. Fathers can make a valuable contribution by taking care of the mother's needs. The father can perform the vital role of caring for the baby while the mother showers or attends to her personal needs. While mother is nestling with the baby, father can prepare meals, do the housework and shopping, deal with the finances, take full responsibility for the care of any older children, and perform many other tasks that will earn him respect and fulfillment. The opportunities for fathers to participate fully in the direct and indirect care of a newborn baby are nearly limitless. Before the baby is conceived, couples need to make plans for sharing the work in an equitable and rational manner that serves everyone's needs. It is when young couples don't have these prenatal conversations and strategy sessions that breast envy is most likely to throw a dark cloud over what should be one of a family's most joyous and relationship-solidifying times.

Common anxieties and myths that undermine breastfeeding
Many fears and anxieties impair or derail a woman's breastfeeding relationship with her baby, or discourage her from breastfeeding in the first place. Some of these anxieties have no scientific basis, while others may stem from illogical magnification and unwarranted generalization of incidents that have happened to only a small number of women.

I have found that the most common myths are generally based on fears of inadequacy. Women can be uncertain about breastfeeding because they have never seen another woman do it. They have been too shy to ask questions about it, and have unconsciously absorbed the anti-breastfeeding messages that pervade our popular media and serve to alienate a woman from her own body.

I won't be able to produce enough milk for my baby.
Human milk is a complex fluid produced in response to the stimulation that the newborn baby creates as he latches on to the breast following birth. Suckling causes the mother's pituitary gland to release two hormones, oxytocin and prolactin. The more the baby sucks, the more milk will be produced. If a mother is not producing enough milk, then the simple solution is to nurse more frequently. The stimulation will naturally increase the production of milk.

In almost all cases, a healthy mother will produce enough milk for her baby as long as he is healthy and she understands the proper latch-on technique. A La Leche League leader or a lactation counselor can help with this. You can judge the health of your baby by observing his development and his social interactions. Watch the baby-plenty of wet diapers every day will tell you that your baby is getting enough milk.

A few mothers actually are unable to produce enough milk. This situation can be caused by hormonal imbalances in the mother, or the baby's failure to latch on properly after birth and stimulate the breasts to produce milk.

An insufficiency of milk can also be caused by supplementing breastfeeding with bottle-feeding. The baby must develop different techniques for extracting milk from human and rubber nipples. Once a baby learns how to get milk from a bottle, she is often unwilling to keep up the technique needed for getting a human nipple to express milk. But no rubber nipple can replicate the elasticity and functions of the human nipple. Without the continual stimulation of a baby's suckling, breastmilk production will fall.

After breastfeeding has been established, some mothers may still worry that they are not providing enough milk for their baby. This anxiety is usually caused by the mother having definite expectations about the duration and frequency of feedings. But no two babies feed in the same way. Mothers can be reassured that every baby will establish the feeding pattern that is right for him or her. Prenatal breastfeeding education will help with this reassurance.

Breastmilk is fattening-I don't want an obese child.
No normal baby ever became obese from an exclusive diet of breastmilk. The myth that human milk is fattening-as if this were automatically a bad thing-stems from propaganda from the formula and diet industries. Fat is a necessary part of the human diet and should be considered a nutrient to be consumed in the proper form and amount. Human milk does have a higher caloric count than cow's milk, but this is because a human baby's fat requirements are much higher than those of a baby calf. We are told that babies generally lose up to 10 percent of their birth weight in the first few days after birth.1 They are then supposed to regain their birth weight within two or three weeks.2 In my clinical experience, however, newborn babies who are allowed to nurse on demand may not lose any weight at all. I believe that it is generally those babies who are nursed according to an imposed schedule who lose significant amounts of weight after birth.

These observations are corroborated by a study of neonatal weight loss among babies in various rural tribes in Zaire. While the average weight loss for all babies was 7 percent, those who were denied colostrum (the milk a mother secretes for a few days following the birth of her child, characterized by high protein and antibody contents) lost twice as much weight as those allowed to nurse immediately after birth.3 Other studies have found that babies permitted to "room-in" after birth regain weight much faster than babies separated from their mothers.4 The reason is that babies isolated from their mothers are generally put on a fixed hospital feeding schedule, usually with intervals of four hours between feedings, and must expend valuable energy screaming and crying before being fed. Babies roomed-in with their mothers are allowed to feed on demand.

For the next six months, breastfed babies usually gain 4 to 8 ounces a week. From 6 to 12 months, babies enjoy a weight gain of 3 to 5 ounces per week. When compared to other babies, some breastfed infants reach the 90th percentile in weight at six months. Every baby, however, is unique-some gain weight slowly, some rapidly. Rather than monitoring your baby's progress by the scale, watch his general development. Other important indices of growth are length and head circumference.

Another important point a nursing mother should remember is to avoid the mistake of comparing her baby's feeding patterns and weight-gain curve to those of formula-fed babies. A breastfed baby will nurse longer and more frequently than a baby on an artificial diet. Human milk is digested more quickly and efficiently than formula, which places a strain on a baby's immature digestive system and makes the baby unwilling or unable to feed for long stretches. The feeding and growth patterns that your breastfed baby establishes will be the right ones for him.

Breastmilk causes diarrhea.
Those who buy into this myth have probably never seen an exclusively breastfed infant's stool; neither do they understand what diarrhea is. A breastfed baby's stools should be frequent, greenish, inoffensively fragrant, loose, and unformed. These are not indications of diarrhea but of health and normality. Adult-type stools will appear once a baby has begun eating solid foods. Formula-feeding will create harder but highly malodorous stools.

Sometimes, of course, babies do fall ill to genuine diarrhea. But a diarrhetic discharge is not merely a loose stool; it is also filled with mucus and blood, and in some cases is accompanied by vomiting. A sick baby will definitely benefit by a continuation of breastfeeding. In fact, acute diarrhea is associated with a lack of breastfeeding.5, 6 It is important that mothers understand that breastfeeding helps prevent diarrhea.

My breasts will leak and ?embarrass me in public.
Leaking is perfectly normal in the early weeks of breastfeeding, and sometimes it continues for months. The gentle tips offered by the La Leche League publications are highly efficacious.7 For example, mothers can breastfeed or express more frequently. They can wear clothing that camouflages the wetness. They can wear nursing pads to absorb the milk. To stop the leaking, they can apply gentle pressure directly on the nipples with the palm or heel of the hand. But denying a baby the benefits of breastfeeding is an inappropriate way to deal with a mother's anxieties about conformity with women who are not breastfeeding. In a society in which the biological aspects of motherhood are kept hidden, it is often hard for young mothers to understand or accept the changes that occur in their bodies during pregnancy and motherhood.

Breastfeeding will hurt or damage my nipples.
In the days when maternity hospitals routinely recommended lactation-suppressing drugs for new mothers, fair-skinned women were often told that they would have sore nipples if they disregarded doctors' orders and breastfed their babies.

A little nipple tenderness is normal in the first few days of breastfeeding. If a mother's nipples are more than tender on the first day-that is, if they actually hurt-and if they later crack, bleed, and cause pain, then she needs help right away. Frequently, the situation indicates a problem in the baby's latching-on or sucking. This problem is easier to correct if addressed early, before the baby's improper suction technique becomes habitual. In most cases, cracked or bleeding nipples can be healed by adjusting the way the baby is positioned at the breast and correcting his technique of latching on.

Sensations of burning and itching are indications of thrush (Candida albicans), a fungal infection of the nipples, milk ducts, and even the baby's mouth. If the mother suspects a thrush outbreak, she should consult her healthcare provider for diagnosis and treatment. There are many ways to make breastfeeding more comfortable while being treated for thrush. A mother can offer short but frequent feedings, nurse on the less sore side, and break the baby's suction before taking him off the breast by gently pulling on his chin, pulling at the corner of his mouth, or putting a finger in his mouth. During and after a thrush infection, mothers should wash their hands frequently, change nursing pads frequently, and boil anything that comes in contact with the baby's mouth.

Fears of nipple soreness will only amplify and exaggerate any transient normal sensations of tenderness, when and if these occur. Teaching girls and expectant mothers what to expect during breastfeeding will do much to eliminate this anxiety, and will increase the number of successful, long-term breastfeeding relationships.

Breastfeeding will take too much time and be too much of a bother.
This is frequently heard from women who have already decided never to breastfeed. Women ambivalent about breastfeeding who hear such remarks often conclude that breastfeeding is more work than formula feeding. When expectant mothers voice such concerns to me, I gently encourage them to examine the issue logically. I point out that breastfeeding is not only the best, most nutritious way to feed a baby, it is also the cheapest. It is free. Formula and its related paraphernalia are expensive. Time that could be spent relaxing on the couch with the baby gently sucking at the breast must instead be spent mixing up formula and washing and sterilizing bottles and rubber nipples-all with one hand while trying to hold the baby with the other. A breastfeeding mother can nurse her baby instantly any time of day or night. Formula-feeding mothers perpetually experience the frenzied rush and delay of running around the house trying to find a clean bottle and mixing up a new batch of formula while the baby screams in hunger.

Some women, however, have no choice but to return to work shortly after giving birth. For them, there is a simple solution: the breast pump. Before and after work, and during the night, a working mother can breastfeed her baby. During the day, the baby can be fed milk that has been expressed by a breast pump and stored in bottles in the refrigerator. Breastmilk freezes well, so generous stores of milk can be made available for use by the baby during the day. This process might involve a little more work than formula feeding, but it's worth the effort in terms of the baby's health.

Breastmilk is not nutritious for infants older than one year.
Breastmilk is a highly complex and sophisticated substance that changes in composition and in the relative proportions of its constituent parts on a daily, even an hourly, basis. In fact, the composition of breastmilk changes both during the day and during a single feeding session. The colostrum that mothers produce in the first few days after birth is not actually "milk" at all, but an immensely important golden syrup rich in nutrients and immunoprotective proteins. After the third or fourth day, when the mother's milk has come in and milk flow has been established, the so-called foremilk is relatively low in fat, while the hindmilk that comes after it is significantly richer in composition.

Research shows that even though the composition of breastmilk is not constant from one mother to another, the mean concentrations of protein, fat, and lactose in milk from women lactating for more than one year are the same as milk composition during the first year. Most interesting, the composition of breastmilk is not influenced by the duration of lactation or even the nutritional status of the mother. Even if a lactating mother is undernourished, she will continue to provide high-quality milk for her child.8 If the mother experiences a return of the ovulatory menstrual cycle while she is still breastfeeding, there can be a rise in the breastmilk concentrations of sodium and chloride and a fall in the concentrations of potassium, glucose, and lactose.9 These changes, however, are unimportant in terms of the nutritive quality of the milk. Even if these minor changes occur, breastmilk remains a high-quality source of nourishment and, equally important, a beautiful and vital way for a mother to provide loving comfort to her child.

Breastfeeding will make my breasts sag, flop, and look unattractive.
This myth is largely a product of televised images of chronically malnourished, famine-stricken women in the third world. It is also perpetuated by the lack of opportunity to observe healthy, educated women in our country breastfeeding their babies in public. Researchers, however, have found that women who are preoccupied with their body shape, and those who want a controlled, less child-centered approach to "managing" an infant in the postnatal months, are less likely to express intentions to breastfeed.10 As one would expect, other research has documented that women dissatisfied with the shape of their own bodies may choose not to breastfeed.11

Although breasts do change shape when engorged with milk, they usually return to their pre-conception size after six months of breastfeeding, even if their milk production remains significant.12 Sagging, however, is a function of age and the cumulative effects of gravity, not breastfeeding.13 It occurs in older women whether they breastfed or not. Thus women have nothing to lose and everything to gain by breastfeeding.

Women with small breasts can't produce enough milk.
Breast size has nothing to do with whether a woman can produce milk. Whether a woman is thin, fat, tall, or short, the basic anatomical structure of the breast is the same for all women, and the glandular structure is unaffected by the amount of fatty tissue in the breast. Lactation variation among women is a result of hormonal differences, not breast size.

Nursing mothers should avoid taking herbs; they can be dangerous.
This statement can be false or true, depending on the herb involved. Many herbs have powerful pharmacological properties, some of which can harm the baby or decrease the production of milk. A cup of tea made with Ephedra nevadensis, for instance, delivers a dose of ephedrine or pseudoephedrine powerful enough to suppress lactation.14 Other herbs, such as chamomile or fenugreek, are harmless and healthful. The smart approach is to check the herbal literature and use only those herbs that are either harmless or beneficial to nursing babies.

Drugs and medications taken by the mother are harmful to the baby.
This depends on the drug or medication. Some drugs may appear in mother's milk in therapeutic doses, but this does not mean that they are necessarily harmful. Depending on the drug, studies find a wide range of infant exposures to drugs in milk. Together with her doctor, a mother needs to assess which drugs she really must take. Mothers taking medications should consult the American Academy of Pediatrics' excellent and detailed statement on the topic of the transfer of drugs and other chemicals into human milk.15 I also recommend the books Drugs in Pregnancy and Lactation and Medications and Mothers' Milk 2004.16, 17 The most rational approach is for the doctor to monitor each nursing mother-baby pair for adverse reactions. Physicians caring for women and infants should be encouraged to individualize their recommendations.

A nursing mother's diet is unimportant.
Diet is always important, and information about diet should be part of the advice given to all expectant parents. We know that the highest-quality diet will produce the highest-quality milk. If you look at isolated nutrients, studies find that whatever the mother eats shows up in her breastmilk. For instance, the results of a fascinating study on the cancer-fighting substance lycopene, found in tomatoes and tomato products, indicate that consumption of a "standard size portion" of tomato products increases plasma and milk lycopene concentrations in lactating women and therefore could increase the lycopene status of nursing infants.18

The amount of scientific literature supporting the importance of a lactating mother's diet is staggering, but I would like to draw special attention to the value of fat in a mother's diet. A mother's intake of high-quality omega-3 fats can also influence her baby's mental development. Omega-3 fats are found in flaxseed oil and in the tissues of cold-water ocean fish, such as cod. We know that docosahexaenoic acid (DHA) and arachidonic acid (AA) are important in the development of the central nervous system in mammals. During the last trimester of pregnancy and the first postnatal months there is a growth spurt in the human brain, with a large increase in the cerebral content of AA and DHA. Studies have documented that the maternal intake of very-long-chain omega-3 fatty acids, such as cod-liver oil, during pregnancy and lactation might be favorable for children's later mental development.19 Children's mental processing scores at four years of age correlated significantly with maternal intake of DHA and eicosapentaenoic acid (both found in cod-liver oil) during pregnancy. To put it bluntly, babies breastfed by mothers who eat a high-quality diet rich in omega-3 fatty acids are smarter than other babies.

Formula-fed babies sleep ?longer than breastfed babies.
While it is true that formula is more difficult to digest than breastmilk, this fact does not translate into longer sleeping periods. Many parents today seem fixated on finding ways to make their babies sleep through the night long before a baby has reached the physiological and neurological stage of development at which this is feasible. As we discussed at length in our book on infant sleep, Sweet Dreams, being awakened three or four times during the night by a crying baby may be unpleasant, but it is simply part of the 24-hour-a-day job of being a parent.20 This fact should be accepted with grace, dignity, and enthusiasm. After all, having a baby and raising a child are among the most enriching experiences a man or woman can have. No job is harder or as rewarding.

The clinical differences between the sleep patterns of breastfed and formula-fed infants are all in the realm of REM and non-REM sleep patterns, not in the duration of sleep. Breastfed infants spend a higher percentage of sleep time in non-REM sleep, and their heart rates during sleep are lower.21

Breastfeeding a baby at night ?will cause tooth decay.
In its most innocent form, this myth is a false extension of the laudable admonition against putting babies and young children to bed with a bottle of formula, sugary juice, or, worst, a soft drink. But there is no danger whatsoever of promoting tooth decay by breastfeeding at night.

Good-quality first-world studies demonstrate that neither prolonged demand breastfeeding nor nighttime breastfeeding leads to a higher prevalence of cavities.22 Researchers have found, on the other hand, that pacifier-sucking and use of a formula-filled bottle at night are risk factors for dental caries in children.23 (See "Big Bad Cavities," in Mothering no. 113, July-August 2002, for more information on this topic.)

Adding cereal to the diet of an exclusively breastfed baby will make her sleep better.
Research shows that feeding infants rice cereal in the bottle before bedtime does not appear to make much difference in their sleeping through the night.24 Before the eighth or ninth month, a baby is unable to produce the enzymes necessary to digest cereal. Introducing cereal into the baby's diet will merely bulk up the baby's stools, and may even result in constipation. One study suggested that formula-fed babies may sleep longer if their formula is thickened with cereal at bedtime, but the researchers recommended this practice only in the treatment of infants with gastroesophageal reflux associated with failure to thrive.25 This is unlikely to be an issue with breastfed babies.

Every baby has a biological right to a loving, carefree, and lengthy breastfeeding relationship with his mother. I suggest that families seriously question any myth, advice, or authoritative-sounding source of information that devalues breastfeeding. When a mother realizes the importance of breastfeeding for the baby and for herself, the father, their family, and our society, she will then be more receptive to finding genuine solutions to any breastfeeding problems that may arise. Breastfeeding can be puzzling or difficult for some mothers, but help is available. I highly recommend that pregnant women learn everything they can about beastfeeding before their babies are born. Books and pamphlets are great; classes are better. Women can gain invaluable knowledge by spending time with nursing mothers: watch, touch, ask questions, and learn.

One thing that expecting families should learn is that breastfeeding is more than just a means of satisfying a baby's hunger: breastfeeding is also about providing a baby with warmth, protection, and love. It is a beautiful and intimate act of sharing between mother and child.

See or call our resource editor at 505.984.6292 for the notes to this article. See for more articles and discussion boards on breastfeeding.

Paul M. Fleiss, MD, MPH, FAAP, is a well-respected pediatrician who has been in practice for more than 35 years. In addition to his medical degree, Dr. Fleiss has a BS in pharmacy and a master's degree in public health. His articles have been published in journals ranging from the Journal of the American Medical Association to Mothering. Dr. Fleiss maintains an active medical practice in Los Angeles.

Frederick M. Hodges is a medical historian and author. After earning his BA at the University of California at Berkeley, Dr. Hodges earned both his MA and PhD at the University of Oxford in England. He is widely published.