Dear Ann and everybody,

In my heart, I believe that the best way for a mom to use formula with
breastfeeding, if that is her informed choice, is just what people have been
saying; begin with exclusive breastfeeding and add formula once the mother's
milk supply is established...whenever that is...or at least after the initial
learning period for mother and baby is over...whenever that is...or anyway
not until the baby has had a good dose of colostrum and undiluted,
unadulterated human milk to condition his or her gut........whenever that is.

But is there EVIDENCE to support this recommendation?  Or are we just hoping
to keep the mom 100% breastfeeding long enough for her hormones to kick in
and change her mind about that formula?

Meanwhile, what do we really know about the normal course of lactogenesis?

Apparently mothers differ in the way their milk supplies get established.
Mike Woolridge observed many mothers through the early weeks of
breastfeeding, and (I remember from his slides at an ILCA conference) among
the many mothers who began making "enough for twins" at first and had to
down-regulate their supply in order to match the baby's needs (this is when
autocrine control kicks in), there were a few mothers who started lactation
producing smaller amounts of milk and gradually increased over a period of
weeks until they were making what we think of as a normal supply.  (I am not
clear about the babies of those mothers---whether they started out gaining
more slowly than the average.  I don't think they received supplements.  I'll
have to go back and listen to the tape again.)

What happens to a mother from the first group, one with an over-generous milk
supply, who starts using formula on a regular basis?  Milk production theory
tells us she will down-regulate her production, and that is what *should*
happen in order to keep her breasts healthy and comfortable.  She has simply
begun the weaning process very early, but there's no point, biologically
speaking, for her breasts to go on making milk in excess of their perception
of her baby's needs.  And it's my understanding that the weaning process,
physiologically, involves involution of the breast and break-down of excess
alveoli.  So even if she began by establishing a full supply, eventually she
will reach a point of no return, where she cannot re-start full milk
production because she has lost too many alveoli.

Does anybody know how long this process takes?  Or what the variables are
that influence its course?

Now suppose her baby does have a bad reaction to formula, or some other
reason comes up to make her want to go back to nursing.  Suckling the baby
can be a stimulus for growing new alveoli.  So maybe she CAN re-build her
supply, IF her baby is interested in being at the breast and IF she decides
that's what she wants to do.

Does anybody know how long that takes?  I heard a La Leche Leader experienced
in relactation say "one week for every month the baby has been off the
breast, plus one more week for good measure."

What if she is one of the "start small and build" moms?  If she begins using
formula too early, then her breasts have less encouragement from an eager
baby, and I don't think she'll ever reach her potential peak output.

And all the time either of these moms is using formula in bottles, that
second phenomenon you mentioned ("the mother never trusts her own body") is
at work.  And the baby is learning some lessons...about the parent's feeding
style, and how it feels to be topped up with formula, and how milk flows from
the breast and how formula flows from a bottle teat, and whether anybody
responds when the baby wakes up or cries "too soon"....

I know that it can get very tiresome to have people like me keep asking for
evidence.  But I also feel as if many of the things we teach about
breastfeeding are part of our lessons because "that's what we've always
said."  Breastfeeding is like a huge puzzle, and we don't have all the pieces
yet.  We have hardly ANY of the pieces, in fact.  We're doing the best we can
with the pieces we have, and I think we're the best help that's available to
moms and babies for now....but that doesn't excuse us from being as rigorous
as we can about insisting on evidence for what we tell mothers.

This is not a criticism of any of my Lactnet sisters and brothers.  Maybe
it's a whine about how many variables there are in infant feeding and how
complicated it is just to understand how exclusive breastfeeding works---and
then women want to go and make it even more complicated by adding another
kind of "milk" from another kind of "milk-delivery system"!

Gives us a lot to think about, doesn't it?

Chris Mulford, RN, IBCLC
puzzled in Swarthmore, PA




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