The answer is not shouting how great breastfeeding is or how "harmful" formula is.

The realities of breastfeeding and how we can better support mothers with Dr Eliza Hannam, GP & Lactation Consultant.

Image via @Loewe

Formula is a dirty word in baby-friendly hospitals and requires a four-digit passcode, secret handshake and, in some cases, a signed waiver that states the hospital is not responsible for your child's future health due to your decision to give your starving and shrieking newborn the devil's drink – but what alternative do we have? All this antagonism for an approved substance that is safe for consumption and, let's not forget, the only widely and readily available food source for infants. 

How we feed our children is deeply personal, at times political and a subject that is always part of a public debate. It is not a decision made by logic or practicality alone. It's led by emotion and, quite frankly, should not divide or define us. Each year, as World Breastfeeding Week rolls around, I can't help but feel slightly saddened. Sad that my journey didn't go to plan. Sad that others are shamed for their decision to breastfeed or not to breastfeed, and sad that we are deflecting from the issue that is the lack of understanding, the need for individualised care, education and support for all mothers, regardless of how we feed our children. 

I spent the first seven months of my son's life petrified of fucking him up. My milk came in late, his reflux went undiagnosed, and we had trouble latching. Yet, I persisted in breastfeeding. When I began to fail, I expressed around the clock instead of sleeping, eating or doing anything to lower my through-the-roof cortisol levels. I did this for much longer than I should have, but at the time, the only thing greater than my anxiety was the fear that his health would dwindle if he didn't consume breast milk. His vision would be poor, his hearing sub-par and his intelligence well below average if I stopped milking myself and gave into formula. 

I know how absurd that sounds, but is any thought considered overly eccentric when you're sleep deprived and in the thick of it? All the breast is best talk does have a way of implanting into our brains, especially when such extreme information is delivered to a room full of first-time, soon-to-be parents by a stern midwife on the danger of any such deviation from breastfeeding. Her words still echo in my mind when a woman, 32 weeks pregnant at the time, asked if all women can breastfeed and explained her concerns that her mother could not. Her response was abrupt and conclusive; "Couldn't or wouldn't. The ones that don't just don't try hard enough." The hidden truth of breastfeeding is that some of us can't. No matter how hard we try. Like many of us, I desperately wanted to breastfeed and tried. And tried. And tried. And tried. Until my mind and my body could not cope. 

Some women never get a chance to try. For others, it is neither physiologically nor psychologically possible. Or all of the above, plus a baby with latching issues, breast refusal and who kicks, screams, wriggles, and arches only to vomit three-quarters of that liquid gold right back up - and this does not even cover premature babies or those born with disabilities that need to be tube fed. Then there are also numerous reasons why a mother's milk doesn't come in or why they can't or do not want to breastfeed. There are practical reasons, mothers need to return to work and do not have the space or time to pump, which is the theme for this year’s World Breastfeeding Week, so their feeding journeys are cut short, not by choice, but because they have no other option.

The common thread with these scenarios is the grief that follows. The anguish of our bodies not performing what nature intended, the heartache of being unable to do what we, the mothers, set out to do. That grief is something that both Dr Eliza Hannam, General Practitioner and Lactation Consultant, and I have experienced first-hand and think it’s important to talk about. Read on as I chat with Dr Eliza about the realities of feeding, how we can remove the shame around formula feeding, what needs to change, and how we can support mothers with their feeding journeys – whatever path they choose or end up on.

JADE FOX: Here in Australia, the rate of breastfeeding is high, about 96%, so it is the norm to breastfeed for the first six months. Much of the data is global, but I want to chat about it on a local scale, as it can vary quite a lot. 

DR ELIZA HANNAM: Exactly. It's worth acknowledging that recommendations and data are from an international context, and some information is less relevant in Australia. In some developing countries, things like access to formula consistently can be a problem, as well as access to clean water, and often in these parts of the world; there are higher rates of preterm birth and infectious illnesses which are conditions that would particularly benefit from breast milk. 

JF: Can you share what you see in your work regarding feeding challenges, why women stop breastfeeding, and what the data tells us? 

DEH: The data tells us that most people choose or prefer to breastfeed at the outset. But there is a significant number for whom it doesn't work out as they'd like. We know that 93% of people initiate breastfeeding at birth, and 39% are exclusively breastfeeding by six months – part of that statistic will be people having to return to work and not feeling supported to breastfeed when they do. But a significant proportion of that statistic relates to breastfeeding difficulties. I'm sure that for some people within that 60ish per cent who start breastfeeding but stop exclusively breastfeeding in the following months, it is an active choice to stop. This might be because it's apparent early on that the benefits that they understand that breastfeeding has for both themselves and their baby are outweighed by the problems that it's causing, or just that formula is the right choice for their family, considering that whole baby, mum and family's health. Whilst they might feel at peace with that active decision, I'm sure they also would, at times, feel judged and shamed. And, you know, that's a whole topic in itself. However, the group that I see more of in my work, which I would argue is the significant majority of that 60ish % who started but didn't continue exclusive breastfeeding, are those whose choice and preference was to breastfeed and then, for whatever reason, couldn't. This might be due to nipple pain, recurrent mastitis, supply issues or other health issues affecting Mum, including their mental health. There are various reasons that feeding might not work out, but it still might not feel like it was their active choice not to breastfeed. And that can lead to huge grief and trauma for some. 

JF: On a personal level, that's precisely what happened in my experience. I wanted to breastfeed, but it just wasn't working, and I decided to stop as my mental health was suffering, as was my relationship with my son. He was diagnosed with reflux, and the feeding issues stemmed from that. He was so unsettled that it made him difficult to feed; I just began feeling too anxious about feeding him because I never knew how it would go.

DEH: And it's just common variations on that. With my child, the issue was breast refusal. I desperately wanted to breastfeed, but it wasn't an option. So I can really understand others who have that experience. Some people feel like discussions around breast versus formula focus on the importance of making an informed choice - but this doesn't acknowledge that formula feeding wasn't their first choice or preference. Still, it's just the decision they had to make. Or there was no decision or choice. That was the only option. 

JF: And the guilt hangs around. I knew it wasn't working for me, for us, and it was making me anxious thinking about it. Then I had to wait to get into a paediatrician. They were closed for Christmas, but I was too scared to try him on formula because I didn't know what would happen or what formula to try. I found that overwhelming. I'd never considered I would be in that position. 

DEH: I think that's the other thing. Whether it’s because we feel shame or guilt or because so much of our focus is on making breastfeeding work, formula-feeding families find it challenging to get support on the practicalities.   

JF: You’re so right. On a purely practical basis, it was hard. I still remember once I did make peace with my decision. My son had to go on a prescription formula – which I wasn’t even aware was an option. We had all these issues, but it's not until you see your baby thriving and happy and so much better that you relax. I still felt a sense of guilt, even a sense that I'd let my husband down! 

DEH: When you have a newborn, and everything you are doing is already so hard and new, feeding takes up most of your day, so it feels so central to your relationship with your baby and your identity as a mother. So when it's not going well, it feels so all-consuming. If breastfeeding doesn’t work out, it certainly helps to see your baby thriving with formula and realise that you can still have a beautiful bond with your baby while you bottle feed. But also, in time, feeding is less of a focus of your whole day. That one thing [feeding] doesn't define your relationship with your child or how good a mother or parent you are. There's so much more to your relationship with your child, and so for many people, whilst there still will be grief, trauma, guilt, or whatever it is. It becomes less.

JF: Yes, the dread of feeding faded, allowing me to let more joy in, which was such a weight off my shoulders. This is more of a systemic question, but I think all hospitals across Australia are baby-friendly, which is pro-breastfeeding. But a considerable part of that forgets about what the mother wants or needs and places unnecessary pressure to breastfeed because, as we know, those rates are high, most already want to breastfeed, and it seems taboo for those who can't or don't.

I still remember being in the birthing classes that my hospital ran, and one of the mothers-to-be put her hand up and explained her mother couldn't breastfeed and asked if it would be a good idea to have a tin of formula just in case. And the midwife's response was a complete shutdown. She fired back a question of couldn't or wouldn't? And went on a rant about every mother can if they try hard enough. Admittedly, I told the group that one of my sisters couldn't breastfeed at all. Her milk just never came in, and I was there when she was trying to do everything she could to get it in, and it just wasn't happening. So there are instances where milk just doesn't come in. Then I was in a position where my son needed formula in the hospital because he had all the colostrum, my milk was delayed, and he was born above average weight and full term and did not stop screaming. He was a really hungry baby, and he continued to be. I was lucky we had an excellent night nurse who recommended syringing some formula, but she confessed she was technically not allowed to ask. But we'd tried everything. And he was still screaming, so this was the last resort, and thankfully, he was content when he had a full belly.

I have spoken to other mothers who have said they had no colostrum left and their milk was delayed, but they were shut down when they asked about formula and sent home with a hungry and shrieking baby for the next few days because they had no milk to give but were warned not to buy formula. I guess the long and the short of the question is, why do baby-friendly policies feel detrimental to mothers?

DEH: If a woman birthing at a Baby-Friendly Health Initiative hospital plans to breastfeed exclusively, then sometimes it's a matter of needing better support with feeding in the hospital rather than the baby necessarily needing formula. There are times when formula is recommended or requested when it's in place of, or when it's not possible to have someone to sit and help with a whole feed or to take the time to assess things properly. I don’t say this as a criticism of midwives or other postpartum support staff; it’s usually related to significant understaffing or similar. 

Or sometimes, formula is offered as a suggestion or a solution for what might be normal infant behaviour, for example, when a baby is frequently feeding, having short naps, or waking a lot, rather than assessing the situation and the baby, and educating a family about normal newborn behaviours. At times, using formula when it might not be needed can undermine breastfeeding being established; at a time when things are potentially quite fragile.

To answer your question, it's probably because of these concerns that hospitals made policies about not offering formula as a routine, but then there are absolutely times when babies need supplemental milk, as was the case for your baby. Policies shouldn’t get in the way of that. Nor should they act in a way that feels detrimental to mothers.

JF: I get it. It's hard for hospitals; mothers' needs and each baby has different needs, and then there are staff shortages and insufficient experts with insufficient time to sit and assess everyone – physically and mentally - how the mother is coping. 

DEH: Regarding what was said in your birthing class, even for the around 7% of people who don't initiate breastfeeding, I assume they would know and understand that breastfeeding has health benefits for mum and baby. They would have had to make what I have no doubt was a considered and, at times, difficult decision about what is best for their baby, their family, the mother, and everyone. So anyone suggesting it's a matter of not trying hard enough, whether or not it was an active choice, is insulting. It's not ever because someone didn't try hard enough. Some Women will give everything, including their mental health, to try and make breastfeeding work. 

The other thing is that there seems to be this idea that all breastfeeding not working out is just due to a lack of support. But that's not true either. Sometimes someone really wants it; they can try hard and be well supported. But despite that, it just doesn't work out. And whether it's because it's having too significant an impact on their health or because the milk never really comes in, there are various reasons. Still, it’s never not trying hard enough or not knowing that there are benefits to breastfeeding.

JF: I do believe that asserting unwarranted fear of formula, and banging in about the benefits of ‘breast is best’ in the beginning, can be more harmful than helpful, as most of us do already strive to breastfeed. We don't need any further convincing. A syringe of formula is not and did not change how I felt about wanting to breastfeed and in my experience, it also did not get in the way of my milk coming in. So my question is, if your newborn is starving, screaming around the clock and/or losing weight, what options do we have?

DEH: Yes. The answer is not just telling people how great breastfeeding is and how "harmful" formula is. The World Health Organisation recommends that if supplemental feeds are required, donor milk is the next best option after a mother's own milk. But most hospitals don't have this available for term babies, and I’ve heard of patients not being allowed to use donor milk they’ve brought to the hospital. So in these cases, it seems almost unfair to follow the World Health Organisation recommendations. If a baby needs supplemental feeds and there's no donor milk available, formula should be presented as an option and without the guilt or, as you say, I've heard of hospitals where people had to sign waivers. Supplemental feeds should absolutely be offered in a non-judgmental way if they’re needed. 

JF: Most of us know the benefits of breastfeeding – even the non-feeding parent understands, and the information is aplenty, but the information on formula is tough to find. There’s no central and reliable site. There are so many variables to brands, types, bottles, teets, flows etc. I didn't know there were different teets for bottles or why one bottle may be superior to another, and I remember thinking I wished I had an expert to ask. 

DEH: People often ask me as a GP what formula brand to get. And I reassure them that every brand available to buy in Australia meets strict guidelines and standards and that it has been specifically designed to meet the nutritional needs of babies. There are subtle differences between the different brands and ingredients that might feel important to some families but not to others, or as in your case; there might be limited types appropriate for babies with specific health conditions and intolerances. I often talk about how GPs need more training in breastfeeding medicine. But we also need to get adequate training about formula... I think I only had a one-hour lecture on feeding in my training. 

JF: For me, making an informed decision means knowing all the information. From experience, I now know that the decision on how we feed can be made for us. Do you think more information should be available on bottle feeding for parents? 

DEH: Yes. I think that there should be information more readily available. I don't necessarily think it needs to be a focus of a lot of antenatal education because we know that most women want to breastfeed. But just discussing where you can find more information about bottle or formula feeding would be a good start. Having evidence-based information and helpful resources available so if you're interested in formula, or intending to formula feed or mix feed, then this is a reliable source of information about the practicalities. That would be a helpful start, rather than it not being discussed at all. And even in the hospital, there needs to be discharge information or advice about where to go from here, especially if supplemental feeds are needed. There should be more education and information going home with the family.

JF: I agree. Having someone acknowledge that formula exists for a good reason and here's where you can find safe information from a reliable source also removes the stigma, and women wouldn't be hit with the guilt if they do use formula or mixed feed, or return to work and breastfeeding or expressing isn't feasible.

DEH: For many families who end up starting formula, despite it not being the plan, it brings up feelings of guilt. And there's sometimes a feeling of shame, which has usually come from the public messaging about breast vs formula feeding. But there can also be a great sense of relief for families with a lot of anxiety around their baby’s growth, health, etc. So it would be great if all those feelings of anxiety and confusion about how to formula feed was removed on top of an already emotional time if families knew where to go to find all the information they need. 

JF: One of the things I don't think is taken into consideration is that when you're stopping or changing how you feed your child, it's a really emotional decision. Regardless if it's a practical decision to return to work, whether for health reasons or it’s just your time.

DEH: Yeah, exactly. That’s why breastfeeding week is so triggering for some or why breastfeeding difficulties are so emotional. There's probably not enough acknowledgement of that. For many people, breastfeeding is not just about nutrition, calories, or health. There's an emotional side, a cultural side, an aspect of reproductive and bodily rights and bonding. For many, the decision to stop is not just a matter of knowing there are wonderful nutritionally-designed alternatives to breast milk. More acknowledgement of the difficulty of these decisions and how inherently emotional it can be.

JF: Absolutely, and it's hard to truly comprehend the heartache until you're the one experiencing it.

DEH: I recently read a book by Professor Amy Brown called Why Breastfeeding Grief And Trauma Matter, and as I read it, there was just so much head nodding because there was so much validation of why breastfeeding not working out can feel so big and so emotional for some. It's worth acknowledging there are some people for whom it's a relatively straightforward decision to stop breastfeeding, and for them, it's more that they shouldn't feel shame. They should feel supported in how to formula feed. But for many people, being unable to breastfeed is so upsetting, on a visceral level, that they can't even really explain it. In her book, Professor Brown does explain why we can feel so emotional about this. 

JF: Oh, her work is fabulous. I haven't read her book yet, but it's on the list! So how can we change the attitude towards breastfeeding and bottle feeding and make it less divisive?

DEH: It has to be an individualised discussion, but it's more complex than telling someone the benefits of breastfeeding and making an informed decision. It's about understanding what is essential or important to that individual. What would they like to do? What are their goals? And to discuss with couples what happens if feeding doesn't go as planned; what feels most important to them? How will they get support? And would they like some more information about formula feeding and how that looks? A more individualised approach acknowledges the emotional aspect of feeding and acknowledges that it's not usually just a simple decision. It's quite nuanced. This would hopefully take away a bit of the 'us versus them' and move towards working with an individual's goals and values and providing the information and support they need to help them get there and make decisions along the way. Finally, there needs to be more acknowledgment that sometimes breast or formula feeding is a choice, and sometimes it’s not, but at the end of the day, everyone is just doing their best. 

JF: Having policies and plans already in place for mothers returning to paid work would mean there is one less thing for them to think or worry about. The theme for WBW this year is "Let's make breastfeeding and work, work!" And the reality is that most mothers return to work, so I'd love to hear your suggestions on how we can and should be supporting mothers in this transition.

DEH: Obviously, it depends on their postpartum stage and how much they are breastfeeding. But regardless, breastfeeding support should be normalised as part of planning to return to paid work after parental leave. So when you're talking to work about rostering and availability, this should be a regular part of that discussion. It shouldn't be up to the parent to bring it up or to need to advocate for themself; it should be part of a policy for all workplaces when someone returns to work from parental leave. It just makes sense, purely economically, if nothing else, to help breastfeeding mothers get back to work if they're ready or when they need to. 

As part of planning a return to paid employment when breastfeeding, you should consider chatting with a lactation consultant, as this is a common concern when returning to work. It might help to sit down and discuss how many feeds your baby has. Does your baby take a bottle? Do you have a pump? How do you feel about mixed feeding? How are solids going? Which is different for every person, and then discussing how breastfeeding after returning to paid work look for you. How do we minimise your risk of getting mastitis? Do we look at day weaning so that you can maintain some breastfeeding but maybe transition to mix feeding if that feels most sustainable? So really, the right path will depend on that family's goals and what’s practically possible. But I think not only should the workplace be instigating and facilitating discussions, but it should also be part of a whole plan with the lactation consultant and others working in breastfeeding support around how to facilitate return to work and how that looks for that specific family or mother.