Besting Breastfeeding Bullies: A Case for Supporting, Not Shaming

"Breast is best" has long been the mantra to new mothers and is a favorite among many registered dietitian nutritionists.

There's no shortage of good reasons for moms to breastfeed their infants; numerous studies point to the nutritional and health benefits of breast milk, including reduced risk of ear infections, sudden infant death syndrome, obesity and respiratory illness, as well as improved maternal outcomes such as a reduced risk of ovarian and breast cancer, Type 2 diabetes and postpartum depression.

For some mothers, however, breastfeeding isn't an option — either because they can't breastfeed or they choose to formula-feed instead. And many of these moms report feeling shame and guilt about their situation.

Has the "breast is best" mantra gone too far in perpetuating these feelings among women who cannot, or choose not, to breastfeed?

Too Much Pressure?
"Bullies" may be a strong label to those who passionately believe that breast milk is the best food for babies — and in most cases, it is likely an unfair depiction of many breastfeeding advocates.

La Leche, an organization that fervently promotes breastfeeding via mother-to-mother support, is sometimes cited as one of the "extremist" breastfeeding groups. Although its approach may seem dogmatic to some, La Leche was founded in 1956 when formula was the go-to choice for mothers, and has dedicated the past 58 years to promoting the benefits of breastfeeding.

Over the years, campaigns and programs to boost breastfeeding among new mothers have been largely successful.

Research from the Centers for Disease Control and Prevention's 2014 Breastfeeding Report Card shows that more than three-quarters of moms begin breastfeeding their infant. Yet despite these promising stats, a study published in 2013 in Pediatrics found first-time moms who report problems and concerns with breastfeeding during the first few days after giving birth are nearly 10 times as likely to quit breastfeeding within two months.

Those findings aren't surprising to Ginger Carney, MPH, RD, LDN, IBCLC, FILCA, FAND, director of clinical nutrition and lactation consultant at St. Jude Children's Research Hospital in Memphis. "It takes a village for a woman to successfully breastfeed," says Carney, noting there are many barriers that make breastfeeding more difficult than it has to be.

"Some of these barriers start in the birth hospital when moms and babies are separated, or when formula is provided to mothers who are breastfeeding," she says. "Other barriers that occur later include unwelcome looks when moms try to feed their babies in public or when new moms return to work and need to find a private place to pump."

Much of Carney's work with new mothers is centered on dispelling myths and providing women with the education and tools to work around these barriers.

Katie Mulligan, MS, RDN, LDN, is an extension service dietitian at the University of Rhode Island whose own experience changed her perspective of formula. Trying to "do the right thing" by breastfeeding resulted in the hospitalization of her 5-day-old daughter while Mulligan waited for her milk to come in. With the help of a lactation consultant, Mulligan used formula to supplement her breast milk. "You think that breastfeeding is natural. No one tells you that breastfeeding can be incredibly hard and heart-wrenching, and that you feel like the world's worst mom when it doesn't work out," Mulligan says.

Many other new moms agree; a 2012 study found that 43 percent of first-time mothers feel guilty about using formula instead of breastfeeding. "My opinion was definitely different before I had a child," Mulligan says. "Now I am much more open to formula as a perfectly good option for babies."

Less Judgment, More Support
Babies not latching on properly, concerns over quantity of breast milk and pain during breastfeeding are typical situations that certified lactation consultant Freda Rosenfeld, IBCLC, encounters in her work with new moms. "I'd say that in 80 percent of cases, I'm successful in helping women achieve their nursing goals," says Rosenfeld, adding that the operative phrase is their nursing goals.

While in an ideal world all women might exclusively nurse, Rosenfeld is also pragmatic: Medical conditions, use of medications, returning to work, fatigue and other factors influence how much, how long and if ever a woman can breastfeed, or if the addition of formula is needed. Each mother's goals, options and situations are different; important points for RDNs to consider and remember when counseling new mothers.

"My belief is that every woman should first and foremost be educated about breastfeeding, and those who want to breastfeed should be helped to be successful," Rosenfeld says. "But no one should ever be made to feel guilty about their choice or circumstance."

Elizabeth Ward, MS, RD, author of Expect the Best: Your Guide to Healthy Eating Before, During & After Pregnancy (Wiley 2009) couldn't agree more. "Women need support for their decisions, not pressure or shame," says Ward. "Being happy is the greatest gift you can give your baby, and if that means no breastfeeding and using formula instead, then that's the best choice."

But sometimes, that's easier said than done. Like many moms-to-be, Massachusetts-based dietitian Dianne Rishikof, MS, RDN, LDN, always assumed that she would breastfeed, but medical issues thwarted her plans. A conversation with her cousin — a pediatrician who holds a strong "breast milk only" stance — left her devastated and feeling like a failure. While reassurance from both her own doctor and pediatrician that using formula would not harm her baby's health helped ease her worries and anxiety, the seesaw feelings of guilt continued for months, perpetuated in part by parenting books she read.

Only after her son turned 6 months old and it was clear that he was nourished, healthy and attached to her did Rishikof come to terms with her circumstances. "I am at peace with this choice that was taken away from me, but I still feel like I need to say 'for medical reasons' whenever I talk about bottle feeding my kids," says Rishikof. "And that need for defensive justification speaks volumes to the pressure or judgment that I must still feel."

Mulligan has spoken out against the pressures mothers face feeling like they are failures if they don't breastfeed and has found support among fellow RDNs, for the most part. However, she says, "There are dietitians who think we should 'warn mothers of the dangers of formula' — that's an exact quote — and that type of thinking does nothing but harm, to the mother and to you, as a health professional."

Using formula to feed a baby is sometimes a conscious choice and other times a decision that's out of a mother's control. Either way, health professionals' roles are to provide less judgment and more support and encouragement — and, of course, science-based nutrition education free from personal bias.

Kerry Neville
Kerry Neville, MS, RD, helps commodity boards and better-for-you food companies translate the science of nutrition into the good food that people eat.