The Breastfeeding Pep Talk.

“Many women feel like they aren’t making enough milk, but you are. You’ll be successful if you keep at it.” These words sprung from my mouth at countless visits with mothers of newborns, often chased by my next sentence: “This is the most precious thing you can offer your child.” With a deeply held commitment to preventive health, I wanted every mother to breastfeed for as long as possible. However, the definition of “as long as possible” changed for me after my own experiences with lactation failure. I’m ready to publically admit it. I am a pediatrician, and my baby drinks formula. My breastfeeding challenges were apparent before I left the hospital. On day 5, I had no engorgement, and my child hadn’t soiled a diaper in 36 hours. The last was still the dark, sticky waste of a hungry newborn. At 1 week, she had lost 15% of her body weight. Her pediatrician gave me a familiar, confident smile. “How often are you feeding her?” “Are you pumping after?” “Supplement for now, but keep at it. You’ll both get the hang of it.” As I breastfed and pumped 12 to 14 times a day for 10 weeks straight, my scant milk became pink with blood from my haggard breasts. I would close my eyes at the end of a pumping session, hopeful that my love for my child would have finally reached the threshold to allow me to give her that most precious gift, and the bottles would be full. But days came and went, and still her weight was stagnant. I took 24 pills daily to improve supply. I once curled up on the bathroom floor around 1 oz of spilled breast milk, the sum of 3 pumping sessions, lamenting a loss that felt impossible to quantify in milliliters. I began to read every study available about breastfeeding. How many IQ points were lost every time I gave a bottle? What was her risk of asthma because of my failure? There were no direct comparisons of formula-fed infants with exclusively breastfed children with concomitant failure to thrive. Unable to know for sure which harm was greater, formula or starvation, I finally did what felt logical. I fed her what she seemed to want to eat, still giving her all the breast milk I could make. I am now finally able to read the articles as a pediatrician instead of a mother, and my heartache is partially soothed. As the painful overlay of my failure dulls, the absolute benefits of breast milk for many diagnoses seem less staggering. Yes, breast milk is best, but is a possible absolute risk reduction for childhood leukemia of 0.000625% better than a chronically hungry infant? Is it worth the self-loathing that poisoned my motherhood experience? I struggled to find literature explaining why my breasts had betrayed my child. I felt as though I was the only woman who truly didn’t make enough milk. Almost every time I interacted with a member of the lactation community, their response to my concerns vacillated between disbelief and pity. I couldn’t shake the feeling that others simply believed my inadequate supply was nature’s way of saying I shouldn’t have been a mother. Through all my years of training, no one had ever told me that breasts could fail. Not once is it mentioned in the entire American Academy of Pediatrics policy statement on breastfeeding.1 Supply problems seem relegated into that dubious category of complaints that physicians simply don’t believe to be “real.” Almost no one I sought out seemed equipped or willing to engage with me in a conversation about lactation failure. They only seemed equipped to give the pep talk. I am not advocating for a departure from the large public health initiative to encourage breastfeeding. I am advocating that our medical community acknowledge that the breastfeeding struggle is not equal for all women and apply an honest assessment of the evidence in a model of shared decision making. Telling all women repetitively that they can be successful in the face of tremendous evidence otherwise might seem encouraging, but it feels cruel. My struggle was with milk supply, but the breastfeeding battle for many is fierce for a multitude of other equally important reasons. Sometimes the risks might be greater than the benefit offered by breast milk. I am merely calling for that conversation. I am asking for kindness when this doesn’t always work out. I am also suggesting a new pep talk. Mine has certainly changed: “Lots of new mothers really struggle, and most of them are successful with a lot of effort. Keep at it as long as you possibly can. I see how much you love your child. That love is the most precious gift you can offer her.”