Sometimes, Breast Isn’t Best (Really)

Photo by NIKOLAY OSMACHKO from Pexels

Establishing nursing with my oldest two children was never a struggle — it was comforting, enjoyable and felt like our special, protected time. My third, a preemie, latched and ate readily but rarely kept milk down, at times even vomiting blood. She struggled to gain weight and was clearly in pain. ‘Push on, continue to breastfeed’ advised my friend, a well-meaning lactation consultant and midwife. ‘Breast milk can’t be the problem.’ But, then we heard ‘Start a prescription formula, stop breastfeeding,’ from our trusted gastroenterologist after running tests, prescribing medications and finally admitting we had run out of options.

My baby had taken to breastfeeding so well that day in the NICU, 24 hours after her early arrival, and it had given me hope. Now, I felt broken, scared and sad, but this was about her health, not about me. I stopped nursing and never looked back. I had failed in my plan to breastfeed my third and last baby for nearly a year, as with my older kids. But, we remained as bonded as ever, staring into each other’s eyes over a bottle rather than a breast, and my baby started to grow and thrive. In our case, breast wasn’t best. Were we really such an exception to the rule?

Breast milk is undoubtedly the ideal nourishment for an infant and baby. Many women plan to breastfeed their babies, and for the lucky, breastfeeding is a rewarding and easy experience that facilitates bonding and nurturance. However, for some moms, the act of breastfeeding can range from difficult, to taxing and painful, to absolutely impossible, and the inability to attain this goal can supercede the joys in having a newborn. Our culture often focuses on breastfeeding at the expense of a new mother’s mental health and wellness, too often forgetting that filling baby’s belly is ultimately all that matters.

Breast And Formula Feeding — A Quick Historical Perspective

Glass Nipple Shield

Breast milk was considered the optimal baby nutrition in the 18th and 19th centuries. Mortality rates were incredibly high for bottle-fed babies due to factors such as poor bottle sanitation procedures, unpasteurized animal milks, and malnutrition. The early 20th century saw a profound reduction in infant mortality owing largely to the introduction of glass bottles and the subsequent release of Liebig’s formula, the first artificial formula considered a reasonable alternative to breast milk. By the 1940s, the general consensus among pediatricians and the overarching opinion of the American Medical Association (AMA) was that formula was a safe alternative to breast milk.

Rates of breastfeeding declined steadily until the late 1960s and into the 1970s. People viewed breastfeeding as an uncultured practice maintained by the uneducated and those unable to afford formula. Many viewed the practice as ‘disgusting.’

Since that time, public support for breastfeeding has swung back into the pro camp, increasing so much over the past 20 years that in some circles there is currently almost a blind enchantment with the practice. Formula advocacy is not about supplanting breast milk at all times for all people but instead reasserting the idea that health of mom and baby is ultimately what is most important; the drumbeat of breastfeeding advocacy sometimes obliterates this message. Let me explain.

Bottle As Self Preservation

Bottle as Self-Preservation

The messaging is not subtle or flexible. One of my patients who attempted to calm her fussy infant with a pacifier during a breastfeeding information session was called out as a ‘bad example,’ told she was being lazy, and ultimately ejected from the event. Nipple confusion is typically cited as the reason why pacifiers should be avoided, yet multiple studies have failed to find causality between pacifier use and reduced rates of breastfeeding. Pacifiers may actually confer safety benefits as they have been linked with a decreased risk of sudden infant death syndrome (SIDS).

Knowing that she was at particularly high risk for postpartum psychosis and that sleep deprivation was, in her words, “the kiss of death,” a pregnant, bipolar patient of mine painstakingly mapped out a plan to fulfill her dual goals of breastfeeding while remaining emotionally well: she would breastfeed by day and have baby receive a bottle at night while she optimized sleep.

Unfortunately, her plan was not honored after baby arrived via a complicated C-section. Shamed for her nighttime formula request, this new mom was woken every two hours by nurses for breastfeeding. A nursery was out of the question; “rooming in” was non-negotiable. After barely sleeping for three days, she was discharged feeling broken and scared and subsequently developed the very postpartum psychosis she had hoped to avoid.

Beyond anecdotes such as these, an extremely common scenario is the woman who initially has no problems breastfeeding but who struggles as time progresses. One such patient of mine became exhausted after exclusively breastfeeding for several weeks. She felt like a shell of her former self, focused as she was on the all-consuming cycle of either planning breastfeeding or engaging in it. Feeding her baby had become a chore rather than an anticipated bonding time. She did not routinely leave the house and could not recall when she last ate a proper meal or showered. She felt disconnected, sad, and resentful towards her partner and developed severe anxiety and depression.

Formula As a Lifeline

Crystal Sanchez: 1 Day Old

Breast milk is the optimal source of nutrition for an infant, yet there are a wide variety of modern formula options that are very similar to breastmilk in terms of nutrients, and sometimes opting out of breastfeeding can actually be protective.

A 2018 study out of UCSF found that supplementing with formula in the first few days of life does not harm baby — instead for babies who had lost significant weight after birth, providing formula reduced rates of hospital readmission (such as for hyperbilirubinemia) compared with babies exclusively breastfed. In rare cases, a bottle of formula can literally be lifesaving. Furthermore, formula in addition to breastfeeding does not lead to premature weaning, as is often suggested by breast-is-best adherents, and does not change baby’s gut flora.

Study after study shows that mom’s mental health is intimately bound to baby’s short- and long-term health and welfare. Consistent data indicates that maternal depression is associated with impaired child cognitive and neuro-development, behavior problems in preschool and beyond, and depression in the teen years.

If breastfeeding is for whatever reason detrimental to mom’s mental health, then bottle feeding is a reasonable alternative. Medical evidence and common sense favor this approach, so it’s a mystery as to why our culture continues to shame moms who opt out of breastfeeding.

Happy & Fed Baby, Happy Mommy

While breast milk is undeniably the optimal form of nutrition for baby, this is not possible or recommended in all situations, as we’ve covered in this article.

The crux of it is that there is no right or wrong answer — the best way to feed your baby is to do what works: breastfeed, bottle feed, do it all — just don’t beat yourself up or feel like a failure.

Whether the breast glands work or not has absolutely nothing to do with whether someone is a loving, kind and engaged mother. The ability to breastfeed has become a litmus test by which one’s worth and value as a new mom is measured, and this is ridiculous. It’s time to move beyond the politics of breastfeeding and respect each parent’s decision for how they feed their baby. Babies need to be fed; the mode is not as important as the love provided while doing so. Being a mom is a long journey with countless opportunities to nourish and support your child — this is only the first.

Originally published at on August 10, 2018.

Psychiatrist specializing in women's reproductive and perinatal mental health, mom to three, skier, & marathoner