In today’s guest post, nurse and lactation consultant Noa Hirsch Choritz explains how keeping formula with medications serves the needs of both breast-fed and bottle-fed babies.
New York City Mayor Michael Bloomberg recently announced that he will be supporting breastfeeding by encouraging hospitals to join the voluntary Latch On NYC program. Among other steps, the hospitals must agree to keep infant formula with medications instead of in mothers’ rooms.
The announcement has been met with outrage and hyperbole, with columnists warning about “forcing women to breastfeed.”
In the maternity ward where I work as a lactation consultant and nurse, we’ve been keeping the formula in the drug room for years. I’d like to share what really happens when formula is kept out of sight and locked up. Hint: No one is forced to do anything and no one starves.
My ward offers exclusive “rooming-in.” This means there is no nursery—all babies are next to their mothers 24 hours a day. Generally speaking, mothers who choose rooming-in are more inclined to breastfeed. Not all the mothers wish to breastfeed exclusively, but our breastfeeding initiation rates are certainly higher. Baby nurseries exist elsewhere in the hospital.
Initially, formula was kept in the patient rooms alongside the diapers, wipes, and clothing. But I often noticed a half-full bottle of formula an hour after my last visit, even though the mother had told me she would be exclusively breastfeeding.
Why did these babies get formula? Sometimes the mother assumed she didn’t have enough milk because the baby was crying. Or Mom would be in the shower, so a well-meaning relative would feed the baby without asking. Other times, I would spend two hours helping a new mom learn to breastfeed and left in the evening when Mom was well on her way to successful breastfeeding. But in the morning I would see that the baby had been given formula all night long by a nurse who either didn’t have the time to help the mother latch baby on, or just didn’t care. It was frustrating.
We also found that many babies were fed enormous quantities of formula. The bottles, distributed free of charge by the manufacturer, contain 90 ml. (3 ounces) of formula – about 6 times more than any newborn could or should eat in one go. The nipples, also provided free of charge by the manufacturer, are designed to have very fast flow rates – much faster than a typical newborn nipple size 0 (and way faster than the human nipple!). Mothers would pump 60 ml (2 ounces) of formula into their 8-hour-old baby’s tummy (which can hold roughly 5 ml at that point). The babies would cry and forcefully vomit out the food.
There is also a hygiene issue: Formula bottles are meant to be used only once, because leftover formula harbors bacteria. But mothers would open the bottle at 20:00 and keep offering from it all night long!
I came up with the idea of removing the formula from the patient rooms as a solution to all of these issues. Eventually we moved the formula to the room where we keep medications, since formula should be viewed as medication: Essential and life-saving when necessary, but potentially harmful in other circumstances. By removing the formula from the patient rooms, we could increase patient-nurse communication, give better care to mothers, ensure that babies who received formula would be fed correctly, and encourage nurses to do what was best for the baby. Nurses are notoriously overworked/understaffed and sometimes (particularly at night, when there are only 2 nurses on the shift) it was easier for a nurse to hand the mother a bottle of formula rather than spend the few minutes helping her. If the nurse had to go down the hall to get the formula, she might decide to spend the same amount of time helping the mother latch her baby correctly.
Our ward has been functioning this way for at least 3 years now. All of our initial goals were met, and we had some surprises along the way.
If a mother comes to our ward and says that she has no interest in breastfeeding (or cannot, for whatever medical reason) she will receive a few bottles of formula, along with a few nipples and instructions on how to use the formula correctly (correct amounts, to dispose of the formula after each feed, etc.). If we think the mother is receptive to hearing about the health benefits of breastfeeding for her and her baby, we may discuss them with her. Again, we use professional judgment. A mother who has birthed and formula-fed many children has clearly heard about breastfeeding before. A first-time mother on the fence may not have.
If a mother has started breastfeeding and is experiencing difficulty, she may ask us for formula. We will try and help her to the best of our ability and if she cannot manage, or is in pain, or exhausted and asks for formula, she will get it. Depending on her situation, we may explain (and not in a judgmental way) how formula-feeding may affect the baby and breastfeeding. Again, we use professional judgment: A mother who asks for formula because she wants to head over to the mall may get a different answer than a mother who hasn’t slept in two days, appears to be one diaper away from post-partum depression, and is not making enough milk (for whatever rare reason). Usually what happens is that we guide the mother on how to best give the formula to preserve breastfeeding, assuming breastfeeding is the goal. This includes feeding the formula from a syringe or spoon, giving the formula slowly (so baby doesn’t get used to a impossible-to-keep-up-with rate of feeding), and giving minimal amounts.
I don’t do the ordering, and we’ve never kept track ( I am now kicking myself for this) of whether our babies consume less formula, or more importantly, whether we increased breastfeeding rates in the long-term. But I still meet mothers who tell me that they never would have continued breastfeeding without the help they got in our ward. A woman recently came up to me in the pharmacy and told me that she managed to breastfeed only the last of her five children, because of me (!). I remembered her: she had come to the nurse’s station asking for formula – she said it was her 5th child and she had never made enough breastmilk so she wasn’t going to try this time. Knowing that there could be a reason for this, I went with her to her room, formula bottle in hand, to chat. The first thing I noticed was the allergy medication on her dresser, one known for drying up breastmilk. Turns out she’d been taking that medicine for 15 years! We asked the doctor for an alternative medicine and magic! – she had enough milk. But I would never have discovered that if she’d been helping herself to formula in her room.
The most amazing for me was the nurse I considered to be the biggest formula-pusher now counsels women to breastfeed! I don’t know whether if it was the trip down the hall to get the formula or seeing everyone else try harder, but it’s wonderful progress.
No one is trying to force mothers to breastfeed against their will, and no one will let babies starve. We simply want to make sure that the mothers (and babies) know what they are receiving and how to use the formula correctly. We don’t want mothers who hope to breastfeed to turn to formula out of desperation or fear. If nurses know which mothers are having trouble, we can allocate our time to those mothers. For mothers who aren’t sure if they want to breastfeed, providing them with a bit of education about the health detriments of formula feeding (ideally well before birth) can make a difference.
In Israel, many babies continue to get formula despite their mother’s best intentions. Along with better policies, we need more licensed lactation consultants in each hospital, and more staff training in lactation for all nurses who work with mothers and babies.
Bio: Noa Hirsch Choritz is a board certified lactation consultant and nurse at Jerusalem’s Hadassah Ein Kerem hospital. She made aliyah in 2002 and lives in Efrat with her husband and 3 small children, Akiva, Hadara (pictured above), and Yonah.
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