Does This Mother Really Have to Wean? Questions Leaders Can Ask
From: LEAVEN, Vol. 33 No. 5, October-November 1997, pp. 117-18
Ed. Note: We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
When a mother's breastfeeding plans are put in jeopardy by illness - its diagnosis or its treatment - she often calls a Leader. A Leader can help by asking the mother a few questions:
- Why does the doctor recommend weaning? If the mother is pregnant, why does the doctor object to her beginning to breastfeed? Is the doctor concerned that breastfeeding, in itself, is likely to harm the baby or the mother?
- How is breastfeeding going otherwise? In some circumstances, such as recurrent mastitis or insufficient weight gain, breastfeeding management information may help the situation.
- Is the doctor afraid that a substance used to diagnose or treat the mother's illness is likely to harm the baby? Is there no information on a particular medication and its relationship to breastfeeding? Does the doctor feel that breast milk substitutes are generally safer than breastfeeding when a mother takes a medication?
- Is the doctor familiar with mothers who have breastfed children of various ages? Is it possible that weaning was recommended partly because of expectations of his or her culture or practice? In some cultures breastfeeding is not seen as important when the baby is older than a few weeks or months. In other cultures people believe that adding breast milk substitutes to a baby's diet ensures that a baby will be well fed. Many health care providers are not aware of the long- and short-term health consequences of artificial feeding for both mothers and babies.
Other questions can help a Leader prepare a mother to seek a satisfying solution when she returns to her doctor:
- Has the mother expressed clearly how she feels about continuing to breastfeed? Some doctors will offer to research a nursing solution when they realize that a mother wants to continue the breastfeeding relationship.
- What effects will "non-treatment" have on the mother and her baby? Will it lead to stress or fatigue which might reduce her mothering perceptions? Will pain diminish her sensitivity to her baby's cues?
- Would an alternative treatment or procedure be compatible with breastfeeding?
- If a temporary weaning is necessary could this be delayed until the baby is older or eating solid food? Could it be delayed until the mother's milk can be pumped and stored?
- Is the prescribed medication all right for a nursing child who is not an infant? Some physicians treat all breastfed babies as newborns when many are not. Guidelines for medications may need to be adapted or changed for an older nursing baby.
Leaders will also need to share information specific to the mother's situation.
In some medical conditions it may be necessary and is acceptable under BFHI Guidelines to give something other than breast milk to a baby. WHO/Wellstart International prepared a list of these in "Short Course for Administrators and Policy-Makers" (see below). Examples of these are: very low birth weight (less than 1000 grams); very premature babies (less than 32 weeks gestation); babies with a metabolic disorder; mothers who suffer from severe psychosis, eclampsia or shock; mothers who need to take anti-cancer drugs. Another circumstance might be a mother with a herpes lesion on the breast or areola that the baby's mouth would touch while nursing (in this case the baby could nurse on the unaffected breast). For information about other viruses such as HIV, Hepatitis and HTLV, see the BREASTFEEDING ANSWER BOOK.
These and other rare situations may indicate a need to supplement, delay breastfeeding or wean at least temporarily. In some parts of the world when a mother is threatened with a condition for which weaning is necessary, parents can choose to provide their baby with the benefit of another woman's milk. It is a paradox that this option is often not available in many affluent countries.
When you think that offering more information or another perspective would be helpful, contact your Area Professional Liaison (APL). She may have additional references or a bibliography to share. In some instances, your APL may be able to put you in touch with a mother who was able to nurse her baby through a similar condition. She also has access to the PL network including the Center for Breastfeeding Information (CBI).
Some mothers may think that breastfeeding and the use of a breast milk substitute are the same for the baby in terms of health. A mother may. assume that when she is ill or needs to take a medication that it is safer to use a breast milk substitute. In poor communities, this misinformation can lead to deadly disease for the baby. In well-to-do areas, it can lead to increased morbidity for the mother and her child.
When a Leader realizes that a mother might be helped by dispelling such misinformation, she might say something like:
Many mothers assume that no matter what medication they need to take, it is safer to wean their baby. Actually doctors who are familiar with breastfeeding issues now think that a mother's milk is almost always safer than any alternative, even if a baby does get a tiny amount of medication through the milk. I want to be sure I have given you all the information I have so that you understand all the options you have. Would you like me to share recent research on the differences in terms of health between breastfeeding and the use of breast milk substitutes?
Questions like these may help a Leader “open the door" for a mother who sees little or no difference between breastfeeding and using breast milk substitutes.
On rare occasions a mother won't be able to breastfeed or will wean her baby out of necessity. In these circumstances, the mother's (or sometimes the baby's) life may be threatened. We, as mothers ourselves, often identify with and are deeply moved by a mother's grief. Many Leaders generously offer comfort to the mother by listening and empathizing.
When we provide a mother with information and support, she is likely to feel empowered to choose what is best for her family. Sometimes her choice is not the same as ours would be and this can be frustrating. Leaders may fear that they have not done enough, contributed enough or empathized enough. It is important to recognize that we may not have all the facts, that we are not able to "walk in a mother's shoes."
When a mother calls because her plans to breastfeed are in jeopardy, the Leader's goal is to help the mother in her decision-making. The PL network can provide a Leader with specific information and also with problem-solving skills that will help her help the mother.
Sharing a perspective on the nature of the breastfeeding couple as well as recent research on infant feeding will help a mother feel well-informed and thus help her gain confidence in her decision-making. Isn't this what all of us in LLL work toward?
Acceptable Medical Reasons for Supplementation
A few medical indications in a maternity facility may require that individual infants be given fluids or food in addition to, or in place of breast milk. It is assumed that severely ill babies, babies in need of surgery and very low birth weight infants (less than 1,000 grams) will be in a special care unit. Their feeding will be individually decided, given their particular nutritional requirements and functional capabilities, though breast milk is recommended whenever possible. These infants in special care are likely to include:
- infants with very low birth weight or who are born preterm, at less than 1,500g or 32 weeks gestational age.
- infants with severe dysmaturity and potentially severe hypoglycemia and who do not improve through increased breastfeeding or by being given breast milk.
For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements. In order to assess whether a facility is inappropriately using fluids or breast milk substitutes, any infants receiving additional supplements must have been diagnosed as:
- Infants whose mothers have severe maternal illness (e.g., psychosis, eclampsia or shock).
- Infants with inborn errors of metabolism (e.g., galactosemia, phenylketonuria, maple syrup urine disease).
- Infants with acute water loss, for example during phototherapy for jaundice, whenever increased breastfeeding cannot provide adequate hydration.
- Infants whose mothers are taking medication which is contraindicated when breastfeeding (e.g. cytotoxic drugs, radioactive drugs and anti-thyroid drugs other than propylthiouracil).
When breastfeeding has to be temporarily delayed or interrupted, mothers should be helped to establish or maintain lactation, for example through manual or hand-pump expression of milk, in preparation for the moment when breastfeeding may be begun or resumed.
For a full discussion of this and related issues see: Chapter 3, “Health Factors Which May Interfere With Breastfeeding ” in Infant Feeding: The Physiological Basis. Bulletin of the World Health Organization, 67, supplement (1989). “Acceptable Medical Reasons for Supplementation ” is taken from “Scientific Basis for the Ten Steps, ” A Short Course for Administrators and Policy-makers, World Health Organization/Wellstart International, 1996.