On Sun, 12 Nov 2000, Jennifer Tow wrote:

> <<  As for counselling my
> patients, I really don't see it as a positive intervention to point out to
> a mother that her child's asthma, or recurrent ear infections, or
> ........(fill in the blank), may be due to the formula-feeding or lack of
> breastfeeding, except in one situation: *the mother is pregnant again* >>
>
> Alicia,
> I would disagree with this b/c women who do not breastfeed have a huge impact
> on their friends who are pregnant. Many mothers think that bf is not very
> important b/c they have friends who have children who do not bf and are not
> aware that those children may be suffering (visibly, they all suffer in the
> long run) from having been artificially fed.
> Jennifer Tow, IBCLC, CT, USA

Jennifer:  You raise a very important issue.  I thought I was being very
progressive (at least when compared with many of my physician colleagues)
but I agree that my silence in some situations may be construed as tacit
approval of formula-feeding.  Not to sound too defensive, I would like to
explain why I have been selective about whom I inform *in my practice*
(which is separate from my prenatal breastfeeding lectures, in which I
tell *everyone* at the class, regardless of how they were planning to feed
their infant, all the risks of not breastfeeding).

Before I go on with that, though, I should point out that I always ask new
mothers on their  first visit how they are feeding their babies.  I then
ask those who answer that they are bottle-feeding whether they had
considered and/or tried breastfeeding.  If they had, then I try to find
out why they are currently bottle-feeding.  If there is anything that
sounds like a remediable situation and they are not too long postpartum, I
bring up the issue of possible relactation (the two usual reactions I get
to this are either blank stares and a pretense that nothing was said at
all, or a look as though I just sprouted a third eye on my forehead; very
rarely, though, I get a mother who actually is interested in this
information and wants to learn about relactating). If they never
considered breastfeeding, I try to get a sense of their reasons and
individualize my counselling.  My experience has been that this group is
generally not open to any suggestions of trying to breastfeed at this
point.

All this applies in cases where the baby is being brought in for routine
well baby check-ups.  Although your point is well taken that a lot of the
morbidity of not being breastfed is not all that apparent, especially in a
society where frequent ear infections, asthma, etc are seen as common
problems in young children, there are actually (a few) formula-fed babies
who do come in just for well baby checks.  Some of these children may
eventually develop some long-term complication of not having breastfed, or
may not.  As a family physician, I have a practice that is based on
continuity (although current changes in insurance coverage have made that
more difficult recently), so it's likely that I will be seeing these
babies from early life (if not prenatally) and for years beyond.  If
that's the case, the mother already knows that I suggested breastfeeding
early on and has either chosen not to follow that advice or couldn't for
some reason.

Unlike smoking or sticking to your diet or using seat belts, all of which
can be modified at some point in the future and still make a difference,
breastfeeding is something that is very hard if not impossible to
re-establish *in a way that might make a significant difference in the
outcome of a particular child*, unless you relactate early on and
re-establish a full or nearly full supply.  So, if my early efforts to get
a mother to breastfeed didn't work out -- or if this mother recently
started bringing her child to me and therefore missed out on my excellent
early advice ;), then it's increasingly unlikely to work as the weeks and
months pass.  Consequently, if the child then presents at 10 months of age
with asthma or at 18 months with diabetes, resuming breastfeeding is not
only overwhelmingly difficult but also unlikely to alter this child's
morbidity by much even if it was accomplished.  As a result, even though I
repeatedly raise the issues of smoking cessation, diet, weight loss,
seat belts, etc etc, in my practice, I have not pursued the breastfeeding
issues with these mothers because I didn't believe it would help this
child and I felt that it would adversely affect my relationship with the
mother.

Having said that, I will work with mothers in special circumstances, e.g.
a mother with a child that has recurrent ear infections or severe eczema
or asthma or can't tolerate a variety of formulas, to either try
relactation or pursue the use of pasteurized donor human milk.  If donor
milk were more readily available and its cost were covered by insurance, I
would use that a lot more than I am currently using it.

Your post, though, certainly has made me rethink my general reluctance to
bring up the issue with formula-feeding mothers, because women don't
hear the direct correlation between the feeding method and their
children's illnesses from most sources.  I have long realized that my job
is no popularity contest, so I guess I should resign myself to a little
less popularity for the common good.  I will give some serious thought to
ways of tactfully bringing up the issue with mothers and would welcome
Lactnetters' input on this touchy subject.  Regards, Alicia Dermer, MD,
IBCLC.

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