Thanks to all who are sending in such varied definitions and eloquent
thoughts about breastfeeding direct or breastmilk-feeding by bottle, and the
values we place on each method.

Over the years I've worked with many, many mothers who start out putting the
baby to the breast ("trying to breastfeed") in the hospital, and then when
this doesn't seem to work, for whatever reason, and I have started focusing
on Rule # 1, Feed the Baby, they find that expressing or pumping breastmilk
works for them.  When the crisis is over and the baby is receiving enough
EBM to thrive, I usually start making encouraging noises about now making
stronger efforts to teach the baby to breastfeed direct.  It is at this
point that some of these moms gradually make it known that they would prefer
not to breastfeed, but are willing to continue giving their babies their own
milk in a bottle because they want their babies to have "the best".

For me this is a difficult moment - wondering whether to provide further
encouragement (to push?) about breastfeeding direct, or whether to encourage
them to continue with breastmilk-feeding by bottle.  I really try not to
make the mother who might be unwilling to breastfeed feel that breastfeeding
direct is so much "better" than breastmilk-feeding that she has falls short
of some kind of "ideal" (mine, her own, her friends' ...)  On the other
hand, I don't like mothers to feel, or to tell others, that they "can't"
breastfeed. I like them to see that they have consciously made such a
choice, because it's more honest, and because then I hope they will feel
empowered.  So I usually offer the information that there seems to be
nothing "wrong" with the breasts, or the baby, and I'm sure that the baby
*can* learn what to do, and I offer to review positioning/latching
techniques again.

Some will try, and go on to breastfeed.  Some will try and still say that
they prefer bottle-feeding EBM.  Some will be quite definite about not even
wanting to try.  I am quite convinced that the last two groups would have
switched to formula feeding had the option of EBM-feeding not been offered
in such a way to make it seem like a vastly superior option.    And some of
these mothers go on to EBM-feed for many many months, and I cheer them on
all the way.   This may seem like heresy, but I also observe several things
about these breastmilk-feeding by bottle situations:

- the mothers can get very good at pumping/expressing, obtaining in one
session much more milk than the baby needs at one feeding, so they can store
it and feed it whenever the baby wants

- babies fed EBM may seem to "last" 3 hours between feedings, whereas babies
who are breastfeeding direct need feeding much more often, I hypothesize
that this is because foremilk and hindmilk are mixed, and because the
bottle-fed baby may take more milk in one "feed".  In many ways this method
of feeding seams much easier to plan, and quicker overall - and some moms
continue because of this.

- logically I would anticipate no difference in a mother's hormone levels
(prolactin and oxytocin) if she is pumping all her baby's needs, or
exclusively breastfeeding - it is only the method of drainage and delivery
which is different.  I remind these moms that because they are producing all
these lovely breastfeeding hormones they will feel very close to their
babies - in the same way as they would if they *were* breastfeeding.

- clearly, some mothers breastmilk-feed because of a *baby*-reason (cleft
lip/palate, neurological impairment, prematurity), and others
breastmilk-feed because of a *mother* reason (convenience, aversion to
having a baby at the breast, history of sexual abuse).  But the effect is
the same - the baby gets the best that the mother can manage.  Personally I
find it easy to support either group.

- within the *mother*-reason group, I cannot remember working with a single
African mother who wanted to do this past the time that the baby was able to
breastfeed.  So it could be that bottle-feeding is a cultural practice
acceptable to some groups and not to others, and that those who are going to
bottle-feed might be persuaded to put breastmilk rather than formula in the
bottle if they are given info/strategies about this option.

I don't think that commercially manufactured "human milk" will ever replace
mother's own expressed breastmilk, because the latter is still tailor-made
for that particular baby at that particular time, with all the antibodies
and other protective factors, and its unique composition still changes
throughout the day and over the weeks and months to meet individual
variations and needs.

I *do* think that we need to be careful not to set such high standards about
breastfeeding that a mother who wants to breastmilk-feed feels that her
efforts are under-valued.  When it becomes clear that a mother I am working
with is *not* going to breastfeed, no matter how I present breastfeeding as
the wonderful activity that it is, then I start focussing on the huge
advantages of the baby having the best possible *milk*, and take it from
there.

And yes, definition is important.  When the baby is taking milk from the
breast I call it breastfeeding direct (and there is partial breastfeeding
and exclusive breastfeeding).  When the baby is not going to the breast at
all, I call it breastmilk-feeding by spoon/cup/bottle, so there is partial
EBM-feeding and exclusive EBM-feeding.  Even to the moms above who I feel so
positive about I don't call it "breastfeeding", because it's not, it's
breastmilk-feeding!

Pamela Morrison IBCLC, Harare, Zimbabwe

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