Just as we and all researchers should be careful about defining "exclusive breastfeeding", I think 
we should also be careful about how we look at lactational insufficiency.  

In the population of moms that I see, I would say that only about 5% of the mothers who see me 
(upon intensive questioning) really exclusively breastfeed.  Its sort of like the study that was done 
on sleep where something like 60% of the parents said their baby sleeps in the crib alone and 
upon intensive questioning it came out that a good 50% of those actually were doing "token" crib 
attempts where they would take the baby back into bed after a few hours.  Almost always when a 
mom claims that she is exclusively breastfeeding, I get some comment near the end of the session 
that there was that bottle of formula in the hospital, or the 6 hour stretch where she doesn't know 
what happened to the baby in the hospital.  Here in Manhattan, none of the hospitals have 
acheived "baby-friendly" status yet.  We are a high intervention culture.  This is the sad state of 
affairs within which I work and I've gotten over it and consider it my mission to compensate by 
getting more breast milk into these babies after their first insult of mostly unnecessary formula.  

The one rampant myth propagated around Manhattan is that formula will make your baby sleep 
better.  I try to judiciously work in the fact that formula fed infants are at higher risk of SIDS and 
now mention this in my prenatal breastfeeding classes, and mention that even babies sleep longer 
after a bottle of formula, it is not safe sleep.  

Now, on the other side - I think it is really dangerous to talk about lactation insufficiency and 
equate it with inability to breastfeed.  Just as we see a majority of women who don't manage to 
exclusively breastfeed, we also see LOTS of women in Manhattan who have undergone fertlity 
treatments. This year, the number of multiples I've seen is done - about 1 per month, but last year 
I had a record month of 6 sets of twins.  I think I've only see 2-3 sets of natural twins.

Almost all of the women I have seen with some primary problem with breastfeeding have been 
able to lactate to some degree.  I think we need to approach these women with some of the same 
strategies that are used for women with breast reduction.  Some really care about the breast milk, 
others really care about baby feeding at the breast and some want both. Its a question of valuing 
what these women are capable of doing and figuring out a feasible plan that enables them to 
optimize either the breast milk, the feeding at the breast or both and give them enough time to 
enjoy the baby too so they are not working 24/7.  There have been a zillion posts about the 
devices and tools that we can use for this.  For some it means SNS or the lactaid system.  For 
others it means strategies such as finding the right breast shield for pumping (which I think needs 
a LOT more research) and making a hands-free bra.  For some mothers with an efficiently feeding 
baby - it may mean leaving them alone to do what comes naturally because the baby will be able 
to maximize supply without anything else.  Each woman's emotional response to the various 
strategies needs to be explored and validated.

Usually when a mom does throw in the towel and quits because some primary problem, I praise 
her for the breast milk she did get into her baby and make sure that she understands that she did 
"breastfeed".  I have not had a single woman to date that didn't at least produce a few drops of 
colostrum and I make sure she feels that those few drops counted.  I think this is very important 
because it can be devastating when a body part malfunctions, particularly one so intimately 
involved in baby care.  These women are very different from the moms who get lazy and start 
letting the baby nurse give more and more formula because "the baby interferes with mom's life 
and she needs a life too".

In terms of the percentages - I think it is irrelevant to our practice.  What is relevant is that the 
strategies we adopt for these various conditions that lead to low supply need to be part of our 
aresenal of interventions.  What we do for the mom who is the copious overproducer and dumping 
her milk down the drain because the baby nurse told her that her baby would sleep better at night 
on the formula is different than what we would tell the mom whose supply has dropped to about 
25% because that same bottle of formula led to another bottle at night, etc.  What we tell the mom 
who has PCOS is different that what we tell the mom who has insufficient glandular tissue.  What 
an adoptive mother might be willing to do may well be different than what a mom might be willing 
to do when she finds out her breasts simply don't have enough tissue to get to a full supply.  

During the years when fewer women were breastfeeding, I think we didn't have to have answers 
for these women.  Basically, if you were lucky breastfeeding went well.   If you were exceptionally 
determined & had no major problems, you could plow through the problems despite having little 
to no support.  The women who had significant problems where a full supply wasn't happening 
were told to formula feed and no one spent time figuring out how to optimze their supply.  

There is one line in a video I otherwise like where they just throw up their hands and say "if you 
are one of the few who can't breastfeed, know that you are just as good a mother".  I want to 
scream every time I hear this.  What a crock!  It should be saying, if you want closeness with your 
baby, see a specialist about using a system to feed your baby at the breast so you too can enjoy 
the bonding or saying, "even if you don't give your baby 100% breast milk, know that you are a 
terrific mother for making the extra special effort to optimize the breast milk that you can give by 
doing some extra pumping.  Then there should be a section on infant massage to help mom and 
baby get some extra bonding and closeness to make up for what mom may miss because of a 
condition she can't help.  

Rather than debating how large that asterisk in the breastfeeding books of the few moms who 
can't produce a full supply is - lets take on the asterisk in the breastfeeding books and help these 
women to realize that even if they can't produce enough breast milk for their babies - they 
certainly can enjoy a piece of the action too.

Susan E. Burger, MHS, PhD, IBCLC

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