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Book Review:

New Thoughts on an Ancient Art

Reviewed by Shana Brown
Colfax CA USA
From: NEW BEGINNINGS, Vol. 22 No. 1, January-February 2005, pp. 4-7

There is an old saying that "the more things change, the more they stay the same." This is certainly true of breastfeeding. Over the past hundred years, breastfeeding has gone in and out and back into fashion, but the basic principles have stayed the same. Breastfeeding continues to help babies grow and thrive. Mothers discover that the more they nurse and respond to their babies the more milk they make. Yet there's always something new to say about breastfeeding, and La Leche League Leaders and health professionals are always finding new ways to help women breastfeed.

That's why LLL revises its classic book, THE WOMANLY ART OF BREASTFEEDING regularly. The latest revision, published in January of 2004, is the seventh edition of a book that was first published in 1958. It is the fifth revision since the book was expanded in 1981.

Do things really change that much in the world of breastfeeding? Yes! Scientific research on breastfeeding is continually growing. So is the practical wisdom and experience that La Leche League Leaders, lactation consultants, physicians, nurses, midwives, and others bring to their work with breastfeeding mothers and babies. What also changes is the way we talk about breastfeeding, and the social context in which mothers nurture their babies. What doesn't change is the LLL commitment to empowering women by helping them learn to rely on their natural instincts about breastfeeding and mothering. And doing this requires that LLL keep its publications up to date.

So, are you wondering, "What's new in the ancient art of breastfeeding and what's old, but still worth reading again?" Here's a look at the latest edition of THE WOMANLY ART OF BREASTFEEDING to help answer all of your questions.

The Old "Blue Manual"

THE WOMANLY ART OF BREASTFEEDING began in 1957 as "A Mail Order Course in Breastfeeding." The LLL Founders, young mothers themselves at the time, planned to write separate chapters and distribute them by mail to mothers who wrote to them with questions. But they soon realized that most mothers needed all the information at once. Their babies were growing and changing so fast that they couldn't wait to get each chapter one at a time. So the individual chapters were published together as a looseleaf booklet in 1958. Seventeen thousand copies of this looseleaf booklet were distributed before the first revision in 1963, which resulted in the slim, dark-blue-covered "manual" that so many mothers used as a "breastfeeding bible."

The Founders chose the title, THE WOMANLY ART OF BREASTFEEDING, because they wanted to emphasize that nursing a baby involved more than medical or technical knowledge. Breastfeeding was an art, like mothering, and there was a close connection between sensitive, responsive mothering and successful breastfeeding. Besides the how-to on first feedings, sore nipples, growth spurts, and plugged ducts, the book offered a new mother the reassurance that she was the expert on her own baby and her own family. Dr. Gregory White and Dr. Herbert Ratner served as the medical advisors for The Womanly Art, and their common sense and respect for the natural processes of birth and lactation contributed to the book's positive impact on mothers' self-confidence. The breastfeeding expertise that mothers found in "the blue manual" came from other mothers' real-life experience, not from distant "experts" in nurses' uniforms or physician lab coats.

This earlier version of THE WOMANLY ART OF BREASTFEEDING served mothers and babies well for almost a quarter of a century. The 1963 edition of "the manual," as it was known to Leaders and LLL staff, was reprinted 29 times. But research about breastfeeding grew by leaps and bounds in the 1970s, as did the number of breastfeeding mothers in the United States, Canada, New Zealand, Great Britain, and other places where there were La Leche League Groups. LEAVEN (the LLL magazine for Leaders) and LLLI News (predecessor to NEW BEGINNINGS) regularly included new and updated information about the advantages of breastfeeding and about breastfeeding in various special situations, and LLL also published many new pamphlets and information sheets with specialized information on breastfeeding. By the late 1970s, everyone agreed it was time to put all the information in one place and write a new and expanded version of THE WOMANLY ART. The result was a book that was three times the size of the original! Besides the very latest in breastfeeding information, it included personal stories from mothers around the world and photographs. The text of that book, largely written by LLL Founder Mary Ann Cahill, is at the heart of today's Womanly Art of Breastfeeding.

THE WOMANLY ART OF BREASTFEEDING is unique among the breastfeeding books you'll find in bookstores or online. It offers the basic information women need to breastfeed their babies, but it also explores other aspects of parenting and family life such as the father's role in breastfeeding, loving guidance of growing toddlers, and family nutrition. It reminds mothers to value "people before things," and it encourages women to reach out to other breastfeeding mothers in local La Leche League Groups to find the emotional support they need in the early years of parenting. One reviewer referred to it as "certainly the friendliest book on breastfeeding." That phrase explains the book's enduring success. Reading it is like having a friend who has been through exactly what you are going through and who can make you believe that you are exactly the kind of mother your baby needs.

Refined Research Techniques and Terminology

The newest edition of THE WOMANLY ART OF BREASTFEEDING, published in January 2004, went through many busy months of revision and redesign. Two chapters near the end of the book received considerable attention in this revision -- chapters 18 and 19, which make up the part of the book titled "Why Breast Is Best." The content of these chapters reflects many exciting changes that have occurred in the study of human milk and lactation since the 1997 edition. For example, chapter 19, "How Breastfeeding Affects a Mother" describes the mounting evidence for breastfeeding's protective effect against breast cancer. Chapter 18 presents new information on the many benefits of human milk for human babies, including decreased risk of urinary tract infections and better responses to vaccines. Both of these chapters are extensively referenced, so the reader who wants to know more can seek out the source material.

Perhaps the most important change in THE WOMANLY ART's section on "Why Breast Is Best" is a new approach to speaking about the advantages of breastfeeding. Through the years, LLL has chosen to emphasize what's good about breastfeeding, and not criticize the use of infant formula. But as the scientific evidence for the superiority of human milk has grown, breastfeeding advocates have pointed out that it is important for parents and physicians to understand that not breastfeeding presents risks. This new edition of THE WOMANLY ART points out:

Breastfeeding is more than a nice "extra," like music lessons or summer camp, provided by conscientious parents who can manage to do so....As more and more scientific studies demonstrate significant differences between human milk and substitutes for human milk, mothers need to know that not only is breastfeeding better for their babies, artificial feeding carries health risks, both short-term and long-term. Holding back information and minimizing the differences between breastfeeding and formula feeding keep parents from being able to make informed choices about their infant's care.

The newest edition of THE WOMANLY ART OF BREASTFEEDING also discusses how research methods may affect the outcome of studies comparing groups of breastfed and formula-fed infants. It can make a big difference to the outcome of a study if infants are exclusively breastfed, partially breastfed, or never breastfed. Similarly, in other studies "just a little bit of breastfeeding in the critical first days of life may also make a difference in some areas, and this could have an impact on research results." Mothers and La Leche League Leaders who read and absorb this material will be better able to evaluate headlines in newspapers and magazines about research on human milk and breastfeeding mothers and babies.

Breast Anatomy and Function

Some of the most interesting new research on breastfeeding, at least for nursing mothers and the people who advise them, has to do with what goes on in the breast during feedings. Using ultrasound to produce computerized images of milk ducts and the milk-making alveoli, researchers have seen that an emptied breast makes milk more quickly than one that has milk left in it. One of the "secrets" of successful breastfeeding that the Founders shared with other mothers all those years ago was the "demand and supply" principle -- the more baby nurses, the more milk mother makes. Now scientific research shows how and why this works! Knowing more about how this demand and supply system works impacts many aspects of breastfeeding management, such as the importance of a good latch-on, how mothers can increase their milk supply, and how to keep up a milk supply for a premature or ill baby. Throughout this new edition of THE WOMANLY ART, the "how-to" sections include an increased emphasis on "finishing the first breast first" before switching sides. The book also describes ways to help a baby nurse more effectively using the technique of breast compression, so that the breast is emptied and therefore stimulated to produce more milk.

Techniques for Better Latch-On

Forty-eight years ago, when the LLL Founders first gathered mothers together for meetings about how to nurse their babies, they would never have dreamed that the subject of getting the baby onto the breast could cover so many pages in one book. In the 20 years since latch-on problems were first identified as the cause of sore nipples, LLL Leaders and lactation consultants have put a lot of time and energy into observing babies at the breast and identifying which techniques for latch-on work best. Each new edition of THE WOMANLY ART or THE BREASTFEEDING ANSWER BOOK presents new refinements. The 2004 edition of THE WOMANLY ART describes in detail the process of guiding a baby onto the breast chin first. This "asymmetric latch" technique helps baby get his lower jaw, which does all the work in feedings, as far back on the breast as possible. It protects sensitive nipples and also ensures that baby breastfeeds effectively.

How to hold or support the breast during feedings is another facet of breastfeeding that has undergone much refinement over the years. The new edition of THE WOMANLY ART facilitates better latch-on by suggesting mothers adapt the way they hold their breast based on the baby's position. A mother's thumb and fingers would make the C shape if baby's head is upright, as in the football hold, and a U shape when baby is lying down in the cradle or cross-cradle hold.

For many, many years, LLL, along with other breastfeeding advisors, maintained that nipple shields were more likely to harm the breastfeeding process than help it. The rubber shields of the 1950s and '60s decreased the amount of stimulation the breast received during nursing sessions, resulting in a decreased milk supply. But today's nipple shields are made of a thin layer of silicone, and lactation specialists have found that these newer shields can help a baby learn to feed at the breast when he just can't seem to latch on effectively. The new edition presents guidelines for using nipple shields with premature babies and other infants, who may tire easily or become frustrated at the breast. Less emphasis is put on the process of discontinuing the use of a nipple shield, because it has been found that babies give them up easily when they are ready to take the breast without them.

Economics of Breastfeeding

One section of the book that is updated in every new edition is the one that describes the cost benefits of breastfeeding. In the early days, the Founders would tell mothers that they could save enough money by breastfeeding to buy a new appliance, which would cost several hundred dollars. These days, estimates of cost savings are even more impressive, especially since the figures in the new Womanly Art include not only household savings, but also information on the impact of breastfeeding on nationwide health care costs.

The Revision Process

Who decides what new techniques and research make it into a new edition of THE WOMANLY ART OF BREASTFEEDING? Just as the seven Founders collaborated on the early editions and on the major revision in 1981, many, many people within LLL contribute to the ongoing process of making sure that our books and publications offer mothers accurate and timely information about nursing their babies. The LLLI Center for Breastfeeding Information (CBI) and the research that is reviewed for Breastfeeding Abstracts provide reference material. Staff members from the LLLI Publications and Education Departments attend Physician Seminars, Lactation Specialist Workshops, and sessions at LLLI Conferences to hear what new things lactation consultants, physicians, Leaders, and others have learned about helping breastfeeding mothers. Members of the LLLI Health Advisory Council read and approve any medically oriented material in LLL publications; other breastfeeding experts may review material specific to their area of expertise.

As new techniques in breastfeeding management become more widely used and accepted, that information is included in the THE WOMANLY ART. The 2004 edition includes information on the use of galactagogues, herbs, and prescription medication used to increase milk supply, since this has become a more widely accepted practice. It also presents new information on vitamin D supplements for breastfed babies, taking into account the American Academy of Pediatrics' newest statements on this subject.

When one LLL book is revised, the changes are carefully noted and applied to other LLLI-published books; the 2004 edition of THE WOMANLY ART benefited from all the work done in 2002 to revise THE BREASTFEEDING ANSWER BOOK. Judy Torgus, the LLLI Director of Publications, supervises the process. Judy has a been an LLL Leader since 1962 and has been the executive editor of every edition of THE WOMANLY ART since 1981. Gwen Gotsch, another LLL Leader who works in the LLLI Publications Department, has also been involved in revising and editing the last five editions of THE WOMANLY ART. Working together with the Founders, Gwen and Judy make sure that new material added to THE WOMANLY ART OF BREASTFEEDING passes the "common sense" test and is sensitive to the needs of mothers and babies.

There is a lot more that is new about the latest edition of THE WOMANLY ART OF BREASTFEEDING. Since the publication of the previous edition, La Leche League International has published several other new books, including HOW WEANING HAPPENS by Diane Bengson; ADVENTURES IN TANDEM NURSING by Hilary Flower; and WHOLE FOODS FOR BABIES AND TODDLERS by Margaret Kenda. These authors are quoted in the relevant sections of THE WOMANLY ART OF BREASTFEEDING and lend a breadth and expertise to new sections on biting and night-waking.

The book has a new cover and a new page design, along with many new photographs showing women breastfeeding in all sorts of settings and situations.

The text has the same friendly tone, with some updated language to ensure that THE WOMANLY ART OF BREASTFEEDING speaks to today's diverse families. The sections on "Working and Breastfeeding" provide information for women who are returning to employment but want to continue breastfeeding, with a new emphasis on providing human milk for all of a young baby's nutritional needs. This part of the book also challenges women to find ways to meet their own needs for "self-esteem, achievement, and self-confidence" while simultaneously meeting their child's need for his mother.

As in past editions, mothers' voices are heard alongside those of doctors and other experts. Funny and touching quotes and stories are peppered throughout the text -- some new, some old favorites. There's the classic story about the mother at the grocery store who was told by another customer that her milk was leaking. Aghast, she looked down at the white puddle of milk on the floor and thought her breasts must be overflowing. But then, to her relief, she discovered that it was the gallon of milk in her cart that had sprung a leak.

You may already own one (or more) copies of THE WOMANLY ART OF BREASTFEEDING. But if you don't yet have a copy of the 2004 edition sitting on your bookshelf, consider purchasing it, either from your local Group or from LLLI. You'll find new information along with the motherly wisdom LLL is known for. The 2004 edition may have the answers you need to better understand how breastfeeding works for you and your baby. Or it may be just the book to pass along to a pregnant friend.

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