The Big Reset: The earliest hours of lactation

It's simple and it's crucial

{Below is a transcription of this audio, mildly edited to remove my verbal filler words, in case you prefer to read or skim this article!}

Hi, and welcome to the First 100 Hours early lactation care teaching strategy. This is going to be the introductory section. We are going to go top to bottom, what this strategy is all about, why it's effective and how we can use it to help others learn how to teach better in the early lactation period. There's so much opportunity there so much potential for people to confuse things.

It's a very easily confused situation and people lose focus on what's important. What we're going to do in this introductory section here is look at what the strategy entails, why it addresses the specific problems that we see and how it can help people to stay focused.

And when I say people, I mean parents, and I mean, everybody who helps to take care of them during that timeframe because those are our main audiences when we're teaching. I want to think about, and I would like you to continue focusing on, how during this timeframe we can remind people to always be circling back to the basics - the things that we know are the most important so that they don't get taken down a lot of side roads. We want to help people, you know, sort of avoid jumping to the next new thing if something feels like it's not working and whatever their expectations are.

We're going to reset expectations for what is actually supposed to be happening and help people to circle back to those basics. The goals of this strategy - let's start with this: we want to help make an impact on exclusive breastfeeding.

That means initiation and duration because one of the things we're really good at is using the Baby Friendly Hospital Initiative to increase breastfeeding initiation rates; we don't really have an equivalent strategy that helps people to continue exclusive breastfeeding.

There are a lot of influences obviously out there in our culture and in our world that are always fighting against exclusive breastfeeding and trying to influence people to use formula, to go away from feeding at the breast and to move into practices which make exclusive breastfeeding really hard or actually impossible sometimes. This is a strategy to help increase breastfeeding duration.

In addition to initiation and what we do in those first days of breastfeeding, it actually matters because it helps determine milk production volumes. It helps determine people's breastfeeding. Self-efficacy, it really just helps to set people's expectations on what things are going to be like.

In the meantime, as we implement this and teach others how to do that, one of the other outcomes will be a decrease in non-medically necessary formula use. Non- medically-indicated formula use is one of those forces that is impacting exclusive breastfeeding in the beginning. And as time goes on, so it impacts both of those things. If we look at this as a strategy whose goals are to do all three of these things, you can see how they all work together.

The strategy really entails a lot of teaching that is going to establish appropriate expectations for new parents, as well as resetting expectations for healthcare workers, because many have been influenced by outside influences like commercial influence to the point where they no longer remember what is supposed to be happening, because what they see happening all the time, doesn't really match up to that.

And so their context on what breastfeeding is supposed to look like in the early days may not be according to the science anymore. It may not match up to what the evidence tells us is actually supposed to be happening at that point.

We want to help people reset what is supposed to be happening and have that understanding of why it's sometimes off why things don't always look the way they're supposed to, and when we need to worry about that, and when it's just a normal variation.

The strategy also gives the opportunity for healthcare workers to provide educational intervention at critical points in lactation. When we're very early on, if we're seeing things that are red flags or we're seeing gaps in information that parents and families have, then we can intervene at that point.

It builds in a lot of opportunities for education, by making sure that people are getting a lot of care that is calm and welcomed by parents, and that actually helps them to feel as if they are being supported rather than somebody rushing in here and there and telling them something, but not really doing anything about it.

That's what we want to teach and support bedside nurses especially to do, to be able to provide the kind of help that people remember, which is honestly the kind of help that involves hands-on. It involves getting people comfortable. It involves adjusting and arranging babies in a skin to skin position that they can maintain for a long time safely.

It's the kind of thing that's memorable because of the brain state, the hormonal state that new mothers are in during that timeframe.

They remember things that they experience and that things that they're touching kinesthetic learning experiences way better than they remember words.

Once we start using a lot of words, a lot of new terms and concepts that they may not have heard before, or bring in a lot of analysis of what's going on that starts to take them out of that nurturing, kinesthetic mode makes it harder, actually, for them to remember the new things that they're hearing, because it's moving them away from the connection with their baby and into trying to hear and understand something that someone else is talking about.

If we can help people to maintain that atmosphere where the connection between mother and parent and baby are maintained and protected, then it's going to be easier for them to experience the things that we expect that they're supposed to be experiencing, which are most optimal for initiation of breastfeeding and optimizing milk production and baby's health and behaviors in the beginning, and help them to avoid things that take them out of that synchronization strategy also calls for ways to provide consistent and evidence-based information to parents using accurate language.

That's really, really important because it is one of the things that parents complain about the most - mothers and fathers alike complain that they're told so many different things about what is supposed to be happening during early breastfeeding and during their baby's first days of life.

It's very critical that we use terms that are accurate and we avoid, for example, terms like milk coming in because that's an inaccurate way of describing how early milk production works.

It sets up an expectation that isn't realistic. We want to use terms that are meaningful because they're accurate and they're evidence-based so that they help people understand what expectations there are and helps them to be able to understand when they see something that is sitting outside of those expectations again, so that they understand when there's something to worry about, versus when things are simply proceeding as normal, perhaps with a small variation.

They're going to be looking for things and be able to recognize what is a symptom of a problem versus what is the outcome of routine.

As we look through the next sections, we'll talk a lot about specific things that that fall into those two frameworks, things that are symptoms versus things that are outcomes of routine.

That really fits in with talking about expectations in an evidence-based way. In this strategy, there is the greatest potential and opportunity to recognize and address risk factors for early weaning before they actually interfere with successful breastfeeding. If the situation has not been ideal when it comes to prenatal care, if the situation has not been ideal or optimal in terms of obtaining information about how to initiate breastfeeding, then there's the opportunity to simply make that happen during this timeframe.

As we have all of this contact with new mothers, we have these opportunities to both observe things that are physical and physiological, as well as to understand what they know and what they're expecting so that we can set their expectations properly and help them look for appropriate markers that things are going well and help them to know if there's something that's not going right.

We also can help to be during this time picking up on things that may have been missed before: anatomical variations that may provide a challenge medical conditions, which may interfere with milk production practices, or things that are going on for a new mother, which might be interfering with breastfeeding.

We have these opportunities to notice things earlier, and that just means more opportunity to help them so that they know what to look for and they know how soon to reach out for additional help.

That's really one of the greatest potentials and opportunities here in the strategy.

Everything that we talk about throughout the first 100 hours and everything we want to be teaching to others is completely in alignment with all of these official policies and protocols.

We've got the 10 Steps to Baby Friendly Hospital Initiative, and we know that that initiative works. Tons of evidence says that the BFHI works, the 10 Steps work. In fact, even just applying a few of the 10 steps makes a tremendous difference in health outcomes and breastfeeding outcomes for a hospital or birth facility.

Of course, what we're going to be talking about here means that we're going to be following all of the 10 steps, but it's important to know that each one of them is critical and has a tremendous impact even on its own. That's how important they are.

We want to keep in mind and make sure that others understand that the Baby Friendly Hospital Initiative is not someone's idea. It's a set of practices which have been developed, according to what the evidence says, results in the best health outcomes for new mothers and their babies.

Breastfeeding is one of those outcomes. Exclusive breastfeeding is one of those outcomes, but health is truly the primary goal, health and safety. And so when we do the things that are included, things like immediate and continual skin to skin care that does have the outcome of facilitating breastfeeding, but it's not breastfeeding in itself. It's for health. It means best outcomes for mothers and babies.

I just really want to key in on the fact that each step there matters even on its own, each one has the potential to have tremendous impact.

There are also clinical protocols from the Academy of Breastfeeding Medicine which deal with this earliest part of lactation both for babies and their mothers. We have lots of ways to look at those protocols, but also remembering that those are based on evidence and they're updated every few years to include whatever is current - current practices around the world.

The American Academy of Pediatrics which just recently in 2022 released some new policies and a technical report on breastfeeding to ensure that everyone understands that pediatricians are responsible for promoting, protecting, and supporting breastfeeding and explains exactly how they can do that. They also have policies on the use of human milk.

Those are all evidence-based as well and provide recommendations for how pediatricians and other physicians can approach breastfeeding scenarios and breastfeeding promotion.

In the United States we also have an organization called The Joint Commission, which provides core measures in a lot of different areas, and what we're talking about specifically here are core measures or practices of perinatal care, which align again with the evidence and which hospitals are able to use to demonstrate that they are following best practices. That impacts their ability to be certified as a healthcare facility and reimbursed for the care that they provide. So it's important in the United States to be following the Joint Commission’s core measures for those reasons. And many other countries have similar organizations which provide that type of health care facility credentialing.

So we're looking at a strategy here with the First 100 Hours which is in complete alignment with every other policy and protocol you can think of because all major health organizations have the same conclusion when they look at the evidence: breastfeeding is a life saving behavior, and it's an important, not beneficial, but important health behavior for everyone.

So when we are talking about the First 100 Hours, we can have the confidence that it fits within all of that framework of being derived from the evidence. It's not just someone's idea of what should be happening. This is all the evidence shows us. These are the best practices to promote health through breastfeeding skin, to skin care and keeping mothers and babies together.

So we can start with setting these expectations. One of the biggest things that can get in the way for new families is really understanding that feeding looks different for babies depending on whether they're inside or outside. So, you know, when babies are in utero, they're getting fed through the placenta and the umbilical cord. There's no effort required. They're getting food all the time.

They're getting what the body says that they need. They're being provided with all of the nutrients and all the oxygen and everything that they need to grow and develop.

But then once they're born and they're on the outside, it takes work to get food. However, they don't come out hungry, needing food immediately. And that's something that, that new mothers and fathers often think is the case that the baby is coming out and needs food immediately.

And sometimes the urgency that's placed upon breastfeeding by staff in the hospital can make them feel that way when it's that the staff may not be putting that urgency on because of a concern about the baby needing food. But it's something that needs to be done. It's a task that needs to be accomplished.

We really want to help everyone: healthcare workers, hospital, staff, parents understand that feeding is supposed to happen at intervals and does not need to happen absolutely immediately when a baby is born because they are not born hungry or lacking. They're born full and they're born with everything they need to last them for several hours.

It also requires that somebody help them once they're on the outside. They didn't need any effort or help on the inside, but it is the responsibility of a primary caregiver, once the baby is outside, to make sure that the baby does feed and is able to feed as frequently as they need to - responsively.

That's what normal newborn feeding is actually supposed to look like. It's not a matter of “the baby was born, so they have to eat within this many minutes or this many hours.”

It's about facilitating the baby to be in a place so that as they communicate that they need to feed, they're able to do so with minimal effort.

And if the baby is with their mother and their skin to skin, this is going to be the easiest place for the baby to be able to both communicate their needs and actually get those needs met. Once we start separating mothers and babies, whether that's into two different rooms where a baby wouldn't be roomed in with their mother, or even just taking the baby, wrapping them in a blanket and putting them in a separate crib - those types of disconnections, they place more barriers and more time in between babies communicating their need to be fed and to go to the breast and that actually happening.

Every time we place that barrier, we make it harder for babies to communicate and for them to have their needs met.

Something else that we know really impacts how breastfeeding get started is that Western societies are a bottle-feeding culture. And that hasn't always been the case, obviously, you know, it’s a modern problem, it's modern times. As care of newborns was taken away and out of the hands of mothers and placed in the hands of a male physicians who claimed that they knew better and gave plans and routines and schedules that mothers were supposed to follow, because they said that it would make things better, we became a bottle feeding culture.

Bottle feeding is very normalized here. And this isn't to say that it should be, or it shouldn't be: it simply is. Bottle-feeding culture is very widely accepted in Western society. It is not the same in other societies. In places where it's not considered as easy to wash a bottle as to use a cup, any baby that needs food away from the breast is fed with a cup.

We're talking newborns, we're talking three month olds, we're talking nine months old there. When you use a cup, it's easier to clean. So if you have limited access to cleaning facilities, because you're working, then you would use a cup, not a bottle. Bottles are very hard to clean, and they carry a lot of risk of contamination, but in our society and in Western cultures, we, for some reason decided that bottles were the more modern or easier way, and that's not necessarily true. Today what we see is that bottles are marketed as being as “close to the breast” as possible, when that isn't really true; they don't really work the same way and babies don't use their mouths on them the same way.

Bottle-feeding culture also ends up meaning that babies are being fed, or that people are trying to feed babies a certain amount, every certain number of hours when that's not what the evidence shows that babies actually do when they're feeding at the breast responsively. As they move away from that responsive feeding and the feeding intervals and amounts start to become the responsibility or the choice of the caregiver, then we again lose that synchronization and that connection between the mother and baby and between the baby and the milk production system inside the mother. That disconnection can create some problems.

We really need to understand that. Even when we're thinking about how to support mothers who choose to exclusively pump or express their milk, we really need to understand how to maintain connection so that they, too, can make all the milk that their babies are asking for rather than some random amount that we've decided is an appropriate amount for a baby to get through bottles.

We need to make sure that we are maintaining the connection as much as possible so that we can support everybody to be able to feed their baby all the milk that they need.

This common belief that babies are supposed to be fed on a schedule every three or four hours: it's very pervasive. It's really, really deep. It's really sunk in for people. And it's something that they think about all the time in terms of is the baby feeding too much or too little, and how they're going to divide that up and how tasks are being divided up among caregivers. There's also this common belief that newborns need large amounts of food.

When you take all of these inappropriate expectations and you place them upon a newborn, all of these inappropriate expectations do not follow what the evidence says babies actually do and what they actually need. We know that in the first 24 hours they need very small volumes of food, as often as they want to get them. We know that in the second 24 hours of life, they need slightly larger amounts of food, as often as they ask, and that as those next 48 hours happen, they begin to need larger volumes of food.

When we start to talk about how milk production works and how milk volume increases during that time, that's where we see how those two things match up: what the baby needs and what the mother's body produces actually come together. It starts out with a very concentrated food that comes in very small volumes that babies can tolerate, and then as the baby begins to need larger volumes and larger amounts of water, milk production, and milk composition change to meet the baby's needs.

When we are able to follow that and have babies fed responsively and facilitate them to feed often, and for as long as they want to, they're able to continue that communication with mother's body that says “yes, I'm here, yes, I'm taking the milk. This is how much I need.” And everything's working altogether.

So why are we talking about a hundred hours? It's really simple. It's just what we just talked about. We can reasonably expect that by 96 hours postpartum - the first four days - which I rounded to a hundred to make it kind of catchy for marketing, 96 hours is a reasonable time to expect that the baby will be feeding well and regularly able to communicate those cues to go to the breast. They're able to suck. They're able to coordinate their suck, swallow and breathe. They're able to void and stool. Milk production is robust and increasing (because generally it's going to be increasing during that time so that the baby is getting what they need.)

The potential challenges and risk factors for early weaning would have been identified through all the contacts and engagement that healthcare workers and hospital staff are having with parents and their babies. There'll be plenty of opportunities to observe things, to hear things and to sort of do that mental analysis of how things are going to understand if everybody should be expecting that things are going to continue to go well.

Or if there's a potential problem on the horizon, all those things should totally be visible by 96 hours postpartum. They may be visible and realizable before that, but by that time, everyone should be falling into that. In addition to that, alongside that if the mother and baby have reached 96 hours postpartum, and there's a problem like milk production has not become robust and it is not increasing.

This is a good “red flag” time to say “this should have been happening by now,” even with all of the things that we know can cause delays of milk production, or milk increase, they should still be happening by this timeframe. Most people who have delayed milk production for any reason that we know comes from birth interventions or post-birth practices, and even from some medical conditions, they should be seeing increasing milk by 96 hours.

Even if they're not seeing all the milk baby needs, they should be seeing some increase.

And if they're not, that is a really critical time to be flagging both of them so that we can make sure that the baby is getting what they need through supplementation, and also that the mother has the educational and clinical intervention that she needs to figure out why her milk production is not increasing and what else can be done to assist with that.

We also should expect that by the end of four whole days of breastfeeding, both mother and baby now have a significant amount of experience. They've done this many times. They've practiced different positions. They’ve figured out what works for them and how they fit together best.

And mother has begun to figure out how to read those hunger cues and those satiation cues. They've gotten into a rhythm of how feeding is working. This is not to say their rhythm won't improve with even more time and practice but 4 whole days of breastfeeding provides a great deal of practice.

That makes a big difference to mothers level of feeling competent and confident about it. There should also have been a significant amount of education provided during all of those contact opportunities. We should also be seeing that all of these best practices we're implementing are leading to optimal outcomes: a baby who has voiding and stooling, a baby who's feeding frequently and a mother who's not uncomfortably engorged or having struggles with latching. If those problems occur, there's been enough intervention to ensure that she knows how to continue seeking help and support to resolve those problems as time goes on.

When we begin every interaction with every dyad, wherever there's a newborn and a mother or a parent, when we begin with the assumption that exclusive breastfeeding is effective and provides everything that a baby needs, then we can look at what is happening and understand if it fits within normal expectations. We can easily see when something is outside of that circle.

And the circle, as I've said before, can have some variations. There can be some things that aren't exactly predictable, but at the same time, this 4-day timeframe gives us a really nice framework to be able to see that by the end, many of these things should be happening.

A lot of people think of the first part of lactation as being divided into sort of two things. The first part is if they've given birth in a hospital or a birth facility, the first part is the part where they're there. And then the next part is when they go home. Well, that can happen at any point within those first 100 hours.

But let's think about this. If they are released from the hospital and they've gone home when their baby is 24 hours old, what we would expect their baby to be doing at that point is really different than if they've gone home at 72 hours or 84 hours postpartum. We would expect a different amount of milk, production, a different amount cuing from the baby to go to the breast, a different amount of milk coming from the breasts, a different level of comfort and how the breasts are feeling for the mother or parent.

So there's so much that can vary. If we are instead teaching people to look at the first 96 hours as one big chunk of time, that they should see this entire trajectory of things that are happening through that, that can help them to actually think about things as what is normal and what is not. Because if they take a baby home at 24 hours and they're expecting what would actually be expected to happen at 96, their expectations are off, so of course they're going to think things are wrong and that it's not working.

We really need people to look at this. We need parents to look at this timeframe as being where all of these things are gonna happen. We also need healthcare workers to look at this timeframe the same way so that we don't have nurses in hospital or other hospital staff, physicians, pediatricians expecting something that isn't reasonable, like robust milk production at 25 hours of life.

We really want people to understand what's normal and what's reasonable to expect so that if they see something out of the ordinary, they can intervene, but they don't overreact to things which are actually normal.

So how can we possibly assume that exclusive breastfeeding is effective in that it gives babies everything that they need? Well, because we have to have something that is the norm, and it is the physiological norm for a baby to be in charge of when they feed: how often that is and how long they stay there and when is the next time they go back. This is what mammals do.

Breastfeeding is a system. And when we trust the system, then we can look for what's normal, what fits in our expectations based on evidence, based on nature, based on biology.

Then we can compare what is happening and figure out if there's a problem or if it's a normal variation. Breastfeeding is the system which evolved in mammals to protect their offspring from infection and at the same time meet their nutritional needs.

If there's a problem with breastfeeding, recognizable signs will appear and be addressed. Many, many people express that they fear that they won't notice or understand if there is a breastfeeding problem. That is very, very uncommon. It is very, very rare for nobody to notice that there's a problem with breastfeeding. There are many places, times and opportunities for a mother to observe that there's a problem for a baby, to signal that there's a problem, or for a secondary caregiver to observe a problem for people around them, for medical providers, healthcare workers, to observe when there's a problem.

This is why we do need those villages around breastfeeding so that there are plenty of eyes on what's happening for mothers and babies, so that we can make sure we're watching out for everybody. But we do have to assume that breastfeeding is all that's needed and that everything will be working until it proves that it's not.

We have to look at it as a physiological norm and understand when variations happen, whether they are true problems or they're simply variations of the norm.

Quick overview of making milk again because as it sits in part of this framework, it's why we can understand why 96 hours make sense and it's how we can teach people quickly and remind and reset healthcare workers expectations for what's supposed to be happening.

Reminding everyone that milk production begins in the third trimester of pregnancy or a little bit before. During that time, it's down-regulated because of the circulating progesterone in the pregnant woman or person. Then when the birth of the placenta occurs - not the birth of the baby, but the birth of placenta - it causes the progesterone level to drop.

And then that change over from colostrum to mature milk is a gradual change. It's not precisely predictable as in “it will happen at exactly this time” or a certain number of hours and minutes after the baby was born and after the placenta was expelled, but it is going to happen during the timeframe within the timeframe of the first 96 hours in almost every case, including when there's a delay.

When that colostrum change over to mature milk is happening, copious milk production is beginning somewhere between 30 and 60 hours postpartum. So you can see where 96 hours make sense as a timeframe to start saying, what is happening here. If there is not robust milk production that is facilitating a baby to have the normal amount of voids and stools during that time…when we think about what should be happening for the baby during this time, we just talked about what's happening with milk production. During the 96 hours, the rhythm of the routine is initiated during this timeframe.

The early frequent feeds lead to normal milk production.

When we minimize interruptions and interference with this rhythm, when we keep mothers and babies together, when we facilitate responsive feeding, when we don't take babies and swaddle them and place them in a different place to lay down when mothers are awake and alert and oriented and could be interacting with their babies. We have to think about what we're doing that interrupts what's going on for mothers and babies that builds their connection.

So as we are thinking about this 96 hour timeframe, we are focused on allowing the mother or lactating parent and their baby to get into a rhythm that involves responding to baby’s earliest cues and allowing baby to feed as long as they want, and then again at the next cues, as much as they want. Not placing arbitrary, outside, external limitations on how long babies can feed or placing arbitrary outside expectations on when they should feed.

Sometimes those inappropriate expectations are placed there because well, babies do have to eat. What happens if they don't eat enough? What happens if they aren't cuing enough?

That's why we have parameters for this. We know the evidence demonstrates that healthy term babies will cue to go to the breast at least 8 times, every 24 hours and in many cases much more often than that.

But if they are not cuing and going to the breast at least eight times, that's a red flag. That's a signal. An intervention is needed.

That doesn't mean that everything in the world is wrong and breastfeeding doesn't work or there's no milk.

It means that some type of observation assistance intervention may be needed which may be as simple as hand expressing milk into a spoon and spoon feeding that to the baby so that they might become a little bit more awake and alert and begin to cue and they can go to the breast again. Not overreacting, but always reacting to those observable signs that do appear if outcomes are not normal.

Common obstacles that parents frequently encounter during their hospital stay their hospital visit or their pediatrician office visits - these are some of the things that are going to be interfering during this timeframe:

• Especially in the hospital. if the baby is very sleepy and/or their parent is very sleepy. There may be a low frequency of feedings or premature ending of feedings as the mother or parent gets tired and wants to be able to put the baby in another place for them to sleep safely.

• Latch difficulties or pain can also interfere with the frequency and duration of feeding.

• Nipple trauma - obviously soreness and pain are definitely going to interfere because nobody wants to do something that often if it hurts and they certainly don't want to do it for a long time. That's an understandable reaction!

• Jaundice or rising bilirubin is something else that gets in the way of breastfeeding and interferes a lot of times with that connection and that communication between baby and mother's body because of the treatments and the interventions that are provided for it. (Overreaction to jaundice can actually interfere more than if we simply understand what it is and we react with the appropriate evidence-based protocols. Then it’s something that can be overcome with minimal interruption to that connection between mother and baby.

• The same thing can happen if the infant experiences weight loss that is outside of normal limits. But again, people must understand what normal limits are in order to understand when something is outside of them.

• Pain and fatigue on the part of the mother or parent can interfere - again, understandably.

• If pain is not managed well, if pain is not taken seriously, this can definitely interfere with their ability and capacity to respond to their baby. We need to make sure that we're always watching out for what is happening to a mother as she recovers from the type of childbirth that she had and any medical conditions that are confounding it

Hypoglycemia or low blood sugar for a baby is another obstacle that can come up which can interrupt that connection and that synchronicity. But again, overreaction causes more interruption where appropriate intervention can actually reduce or minimize the types of disconnection that can happen when a baby has low blood sugar and needs an intervention.

Then there are some false justifications that parents are, you know, that they find themselves hearing where formula is advised either in the hospital or in their pediatrician's office without medical indication - some of those are going to include things like the mother needing an MRI or diagnostic imaging because of a symptom or something that's coming up after the birth. That's a false need for formula in most cases; use of medications without specifically getting that justification, that rationale from the appropriate resources.

Sometimes people are simply told, well, you're taking a medication so you can't breastfeed, and that's not how that works. We need to make sure that we're providing people correct, up-to-date information about the specific medication they're using, how that impacts milk, how that impacts safety for the baby and how that impacts milk production. So we need to give people specific information, not generalizations about medication and breastfeeding.

Sometimes people who opt to undergo a tubal ligation or need any other kind of surgical procedure while they're in the hospital are told that they cannot breastfeed, or the procedure itself interrupts their connection with the baby. If they're not facilitated to make sure that they feed right before the procedure and as soon as they get back to their room, that can really interrupt that connection between them and can get in the way of the baby cuing and being able to be fed responsively and enough in order to “get enough.”

Sometimes hospital staff, bedside nurses, and other people in the lives of a pregnant woman or person tell them that because they smoke, they should not breastfeed, and that is simply not true. That does not fit with the evidence that we have or the recommendations of any major health organization. There's education that should be provided to people who smoke and there's important safety information that needs to be given to new parents if they're smoking in the home or by people who are going to sleep near the baby, but smoking does not mean you cannot breastfeed. And it doesn't mean you shouldn't breastfeed. That's something that leads to people to be told to give formula without cause, without evidence.

Sometimes people are advised to give formula simply because the baby won't latch, but no one's shown the mom how to express her own milk, whether that's hand expressing or using a breast pump.

Formula is for when there's no milk available. If you didn't try to get any milk out or you didn't make human or pasteurized donor human milk available, how would you know if milk is available? Just because the baby didn't latch doesn't mean that there's not any milk.

It's really important that we are helping people to reset that thinking: when the baby's not latching, that's not because there isn't milk.

It’s a completely separate thing that we need to look at completely separately and make sure that we work on both the latch and making sure that we get milk out, both to feed the baby and also to protect and maintain milk production.

Sometimes people are told to give formula if their baby has any kind of physical anomaly, something that will require surgery either soon or later down the road, sometimes because they might have a cleft lip or palate, they might have a heart condition. They might have a tongue tie or a lip tie.

These things are not indications for using formula. The indication for using formula is either a medical contraindication to breastfeeding, which are rare and we'll of course go through those, but also that mother's own milk is not available.

It's really easy to see now, when you think about this, that how these false justifications, that so many people encounter that can make it really difficult for them to understand what's supposed to be going on. Then you couple that with the misperceptions, the stubborn myths that are out there that are so hard to eliminate from culture and from what people say and think, so people think there's no milk in the beginning.

They think that babies should eat and then sleep immediately for long periods of time. They think that babies should only feed for certain amounts of time or switch breasts after a certain number of minutes. They think that there should be a certain amount of time in between feedings or it's not a real feeding. They believe that you need to pump to get milk out, that there's no other option, that hand expression doesn't exist. They believe that other people need to feed the baby, especially in the beginning, to either get them used to it or anything like that. And that's simply not true. They misunderstand or have inappropriate expectations around infant weight loss, and think that early infant weight loss is absolutely always a problem

when some amount of infant weight loss very early on can be normal. They think that they need to know how much the baby is getting and that's not possible to know to a certain degree from the breast, unless you're in an environment where there's a scale, but for most people they're not weighing babies so they can't see how much there is.

Belief and myth persists with healthcare workers as well because they have a need to document what's happening and it can be hard for them to feel confident in what they're documenting if they aren't sure what to look for outside of hard data, like “the baby had this many milliliters of milk.”

They may look at diapers as a direct reflection of intake; that's a misperception as well. That's an inappropriate expectation. Early diapers do not directly reflect what babies are taking in, and that can really throw people's expectations off.

Then you've got people feeling or believing that birth interventions don't have any effect on breastfeeding or that that's just something that people say to scare people out of birth interventions. What we know is that evidence shows the effects of certain birth interventions on early feeding and milk production.

We also see people completely misunderstanding the early term or late preterm baby and putting expectations on them as if they are healthy and term. They are not the same as a healthy term baby. Their behaviors are different and their feeding shouldn't be looked at the same way either. They're not “just a little bit smaller than term.” These babies are actually less mature in the ways that affect feeding.

There's also beliefs that are very persistent: that preterm infants must prove that they know how to bottle feed and they can do it effectively before they're discharged into the home, which doesn't make sense if parents aren't expecting to be bottle feeding at home. Preterm infants can absolutely breastfeed and there are many things that need to be done to support that.

Many people simply believe that formula fixes a breastfeeding problem, that if you just give some formula, then the baby will be better and breastfeeding will be possible. They don't think about the fact that giving the formula actually interferes with many things. A lot of people believe that a little bit - a small amount - of formula doesn't actually have any effects or might even help, and that simply isn't true. We know from the science that formula in any amount does have effects on babies and does have effects on breastfeeding and same with pacifiers.

We know that there are effects on breastfeeding milk production especially when pacifiers are used early. It's important to have these conversations so that people know what they're looking for and what kind of practices are interfering.

We also hear people talking about that the baby might be using the breast as a pacifier, which, again, if we help people reset their thinking to the understanding that breastfeeding is the physiological norm, and that babies are going to communicate their needs, not their wants, then we understand that they could not be manipulating and they are not asking for something that they want. They're asking for something that they need, which is to suck. And if they're asking to suck, that is supposed to be at the breast. It's the physiological norm.

People are misreading crying as a hunger cue when there are many earlier hunger cues that need to be responded to. If people are waiting for crying, they're waiting until very late hunger cues, which can make feeding more difficult.

People believe that deep infant sleep is the goal, that that's what we want. So we're going to wrap them up tight. We're going to make them super warm. We're going to make them super full and we're going to make them sleep for a really long time… when that is not developmentally or physiologically what newborns need.

We need to reset people's expectations to understand what newborns actually need during this time that they're transitioning from the womb to external life. They may believe that if the baby is feeding very frequently or asking to go to the breast very frequently, it's because they're not getting enough milk.

They're not understanding that the baby is asking to go to the breasts so that they can get enough milk and so that they can signal the body to make all the milk that they need.

So rather than, you know, facilitating the baby to get the milk they need, sometimes interventions happen then do prevent the baby from getting all that they need. That belief we talked about, that babies are born hungry, and that they need so much in the beginning really can interfere. And that sense that people tell mothers, they don't have milk if they aren't feeling full or they're not leaking, or they don't feel let down. Those things are not necessarily indications of anything. Those can interfere even though they're not true. What happens is when all of these obstacles and false justifications and common myths and misperceptions are coming together, all of this bad information leads somewhere.

What ends up happening is that parents hear and their overall perception is that breastfeeding is usually or always problematic.

They mistrust in the process. Healthcare workers do this all the time. They believe that all these things that they see mean that it's breastfeeding that is the problem, and so instead of trying to fix breastfeeding in each situation, they simply come to believe that it's always difficult and it's always going to mean extra work to support breastfeeding parents or that it's not worth it.

All of these pieces of that information can lead to overreaction. You know, not understanding what is normal and what are normal expectations. They can lead to overreaction and unnecessary use of formula and other interventions that interfere with breastfeeding and milk production. Overall, they lead to the erosion of the lactating parent or breastfeeding mother’s sense of self-efficacy around breastfeeding and infant feeding in general.

When we take things away, it makes people feel like they aren't able to do it. And they feel vulnerable, very vulnerable because fundamentally it matters to birthing people, whether they are able to accomplish feeding their baby. It's not just an intellectual thing to say, “well, breastfeeding, isn't working, so here's my new plan: I'm going to exclusively pump and bottle feed, I'm going to combination feed, I'm going to use formula and bottle feed my baby.”

That's part of the equation. But the other part of the equation is a very deep emotional vulnerability that can be opened up for people that can be difficult for them to process.

We have to look at feeding transitions and feeding difficulties as times of great vulnerability for people to be making new decisions because if they're making those decisions because they feel like they can't feed their baby, that really can cause them a lot of grief and a lot of emotional vulnerability that they may not be able to process.

It may cause them some problems with bonding with their baby. It may cause them some difficulty and it can cause other mental health effects. We want to make sure people are always being supported at every step of the way.

This is a really vulnerable timeframe in these First 100 Hours. There's so many changes going on. We want to be there to support people with the right information so that there's no overreaction and there's no outside influences making breastfeeding harder, or even in some cases really not even possible. We want to eliminate that.

We know that some of the things that influence what's happening for breastfeeding are coming from Western media models and ideas about what breastfeeding is that it's something to be poked fun at or joked about in mass media, on TV and in movies, or that it's something that always comes up in the news as “this person was harassed for breastfeeding in public” and “should breastfeeding in public be allowed” or whatever questions they ask that make people start to question breastfeeding as a normal behavior.

Unfortunately, commercial influences are huge, huge, huge impacts on parents' feeding choices and their ability to feel that they are able to accomplish the task of feeding because there's all these products out there.

There's a lot of ways the commercial influences impact this; not only does it impact them in terms of formula being marketed to them, but many products. The fact that there are so many breastfeeding products being marketed to people also can lead them to feel as if breastfeeding is something that requires a lot of financial resources to acquire those things. And if they can't afford that, how do they feel about their ability to feed their baby? There's a lot of tricky and sneaky ways that this works, but there are also messages that come through the marketing of products and formula that tell mothers that “you might not make enough milk,” or “your milk might not have everything that your baby needs.”

Those things are not true. Hearing those messages over and over can have a huge impact on people.

We also know that the lack of medical education, that incredibly tiny amount of time that is spent in nursing school and in medical school on learning how human lactation works - it's a laughable amount of time when compared to anything else. Although many people say that nurses and doctors don't spend any significant amount of time on nutrition either, and nutrition is one of the building blocks of health. So as you know, part of that whole umbrella - very little time is spent on that. Most of the time is spent on dealing with problems.

It's easy to understand why if you've been through medical education and you didn't learn about how human lactation works and your whole focus is on how to solve problems, then you're looking for problems to solve. Then when somebody comes along in front of you who's breastfeeding, you're looking for the problems. You're not looking at it to see how it's working and how things going. You're looking to see if there's any problems that they need you to solve.

There are times of course, when formula is medically indicated or it's chosen by a parent and that's the time to say “Here you go, here's the formula that you needed. Here's how to prepare it safely. Here's how to use it. Here's how to feed it to your baby. Here's how to store it. Here's how to get more if you need more or when you need more.”

There are times when formula is going to be medically indicated, and we really want people to be thinking about what those occasions are and also including choice. Personal choice as something that is the time when turn that power button on and say yes and provide all the education that people need around that.

We want to think about why we're avoiding formula, because really a lot of this strategy is about helping people to avoid using formula unnecessarily. Why would they want to do that? Why is it really important to avoid formula when we can? Well, because there are risks that are demonstrated by the science and the evidence, and we want to be realistic about what those risks are.

It's not a matter of trying to scare people out of it, but it's a matter of helping them do the things they need to do in breastfeeding and milk expression so that they don't have to use it unless they have to or they want to.

Just thinking about it in those terms can help change the mindset of somebody. When we're working with healthcare workers, when we're trying to teach them things about how to approach this, this is a really important point to make that the point is to not have to ever need to use formula, right? We want to avoid it if possible because there are risks and they're not small, they're not negligible. Using formula even once, even small amounts, can impact breastfeeding in a meaningful way.

We want to help people avoid using it if they don't have to because it does impact their breastfeeding journey.

As we think about those things, think about those resets, that we want to help people find those different ways of thinking about it that are going to help them look at breastfeeding as the thing that we want to make sure is going well rather than finding ways to intervene with formula, or if there is a need for any kind of intervention, understanding that avoiding formula should be the ultimate goal if it's at all possible because there are other better answers to most problems where formula won't be necessary.