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When Breast and Bottle Both Are Best

Like many pregnant women, Clara James planned to exclusively breastfeed her baby-to-be throughout his first year of life -- as much for the nutritional benefits as for the bonding time nursing would provide. And at first, it looked as though the 39-year-old New York City mom's dreams would come true. Even after a difficult cesarean section, baby Zach nursed in the hospital, latching on well.

But once home, Clara's blissful ideas of breastfeeding were turned upside down. "If Zach wasn't on the breast, he was crying," she remembers. "The lactation consultant I called weighed him after a feeding and said she wasn't sure he was getting enough milk. But she told me not to supplement and to put him on my breast as often as he wanted to be there, which was every hour and a half." She followed the consultant's instructions, using a supplemental nutrition system (or SNS, a device that allows milk to be suspended in a container around a woman's neck and delivered to a feeding baby through a tube laid next to the woman's nipple) while she breastfed as well as pumping in between feedings.

Clara, who was taking a few months off from her job, managed to keep up with this grueling schedule for several weeks. Eventually -- rundown, tearful, and anxious about her baby -- she developed mastitis. Zach got thrush (a yeast infection of the mouth) from Clara's antibiotics, Clara herself got nipple thrush, and, on top of all that, Zach was still crying all the time. Meanwhile, she hadn't slept for more than a two-hour stretch since she'd given birth. "Because of the terrible fatigue and my anxiety over his not gaining much weight," she says, "I thought I might have to give up breastfeeding altogether, which I really didn't want to do."

Fortunately, Clara's pediatrician took one look at the crying, unhappy baby and mom on the verge and advised Clara to supplement with formula, right away. Although her lactation consultant had warned her against it, she felt that she had exhausted all other options.

Almost immediately, the situation improved. Zach, finally satisfied, switched easily between breast and bottle. Clara's anxiety lifted, she got more sleep, and she began bonding with Zach during feedings. "I guess I just needed someone to give me permission to supplement," she says. "It made our lives easier, and we still had the advantages of breastfeeding. But no one ever told me I could do it."

Doing the Combo
Okay, before an army of lactation consultants rises up in protest, let's be clear: No one is questioning whether breastfeeding is best. It's not only the clear nutritional choice, but it provides a closeness to one's infant that borders on magical.

But let's also finally admit it: Breastfeeding exclusively is extremely difficult for some 10 to 20 percent of women, says James Sargent, M.D., a pediatrician and researcher at Dartmouth Medical School, in Lebanon, New Hampshire. And according to Babyalk contributing editor and lactation specialist Marianne Neifert, M.D., author of Dr. Mom's Guide to Breastfeeding and one of the country's top experts on the subject, up to 5 percent of women suffer from breast milk shortage, making exclusive breastfeeding practically impossible.

But when one of these frustrated moms hears from ardent breastfeeding advocates that she shouldn't supplement with a bottle (let alone formula), she may decide to abandon breastfeeding altogether, thinking it's an all-or-nothing proposition. "Moms are often told very strongly that regardless of how hard a time they're having, they should breastfeed exclusively," says Dr. Sargent. "But that may not always be appropriate. The downsides (ranging from a distressed baby and a miserable mother to a malnourished and dehydrated infant) can actually outweigh the benefits."

The answer for many women who struggle with exclusive nursing may be to combine breastfeeding with bottlefeeding. Many experts agree that some breastfeeding is better than none at all.

A Medical Necessity
Clara's situation -- her baby simply wasn't getting enough breast milk -- is one in which a breast/bottle combo may be medically necessary. Usually, your child will give you an indication that feeding's just not going right, but for many moms, it takes a good pediatrician to back up their hunch. "If I see a newborn who just seems miserable and hungry and who cries all the time, I look at that very seriously," says Dr. Neifert. "It can't be a positive early life experience for a baby who is frantically hungry to be put to the breast and not get enough milk."

If you suspect that breastfeeding isn't satisfying your baby, ask your baby's doctor to help you confirm the problem. Your baby's weight is a good indicator of how well she's feeding, and there are two ways to evaluate this. Since newborns shouldn't lose more than 10 percent of their birth weight in the first few days of life and should surpass it by 2 weeks of age, your pediatrician may weigh your infant while she's naked to compare her current weight with her birth weight. Another weight test involves what doctors call a "representative feeding," which will give your pediatrician an idea of how much milk your baby takes at a typical breastfeeding. To do this, he'll weigh your baby with her clothes on, ask you to nurse her, and then reweigh her in the same clothes. The change in her weight after a feeding represents the amount of milk she drank from your breasts. "By two to three weeks of age, for example," says Dr. Neifert, "a baby should be taking in about one ounce of milk per hour. So, we would expect her to have gained about two ounces two hours after she nursed. If the gain is considerably less than this, there may be a problem."

Dr. Neifert also suggests that you ask your ob-gyn to do a thorough "lactation assessment," which should include a medical history to uncover any conditions, such as breast surgery or hormone problems, that could interfere with successful breastfeeding. Ask your doctor to evaluate your breast appearance as well -- including size, shape, and symmetry. Some women, says Dr. Neifert, through no fault of their own, have underdeveloped breasts that render them unable to make enough milk, and small-breasted women may have to nurse more often because their breasts may not hold as much milk, increasing the chance of nipple sores, cracks, and bleeding. "This is a biological difference in women that no one will admit to," says Dr. Neifert.

When faced with a mom who is physically unable to supply enough breast milk to her baby, Dr. Neifert usually recommends what she calls a "triple feeding":

1. Temporarily restrict the duration of breastfeeding to 20 minutes (10 minutes per side).

2. When you finish breastfeeding, have your spouse or another caregiver feed the baby as much extra milk (either previously expressed breast milk or formula) as necessary to satisfy her. (A breastfed baby often accepts a bottle more readily from another caretaker because she expects to breastfeed from her mother.)

3. While your baby is drinking her supplement, use an electric double breastpump for 10 minutes to extract any residual milk in your breasts and stimulate additional production. Refrigerate the milk you express.

4. At the next feeding, repeat the cycle. After breastfeedding, supplement first with your expressed milk, then offer additional formula as needed.

Over time, says Dr. Neifert, triple feedings will help build up your milk supply while assuring your baby is adequately nourished, and you may be able to return to exclusive breastfeeding if you wish to. The rigors of a triple feeding schedule aren't for every woman: some are too exhausted or have too many other responsibilities to devote the necessary time and energy to this demanding regimen. "It's important for the mother to choose whether she feels she can add in pumping," says Dr. Neifert. If you'd rather not, you might want to follow the instructions below.

What's Best for You?
Even when the baby's weight is not a problem, maternal complications like physical illness, mastitis, nipple pain, clogged ducts, fatigue, anxiety, or postpartum depression can interfere with a woman's enjoyment of breastfeeding and her commitment to continue. In such cases, says Dr. Neifert, "if a mom's emotional well-being is at risk because she keeps trying and trying and it's still not a rewarding experience, we have to assess whether it's realistic for her to exclusively breastfeed. Many moms who are having a great deal of trouble and are ready to quit will breastfeed longer if they see it as doable for them" -- doable, in other words, by combining breast- and bottlefeeding.

Consider 41-year-old magazine editor Jane Peterson's experience. "When I had Ben six years ago, there was less awareness than there is today about what to do when you had breastfeeding problems," she says. Jane had planned to breastfeed exclusively for several months, but within the first week, she experienced a number of problems. "Ben wanted to nurse every hour," says the Cleveland, OH, mom. "He was a big baby, and he was hungry! He was gaining weight and my milk supply was fine, but I wasn't sleeping. Into the second week, my nipples were sore, cracked, and bleeding, Ben was still feeding once an hour, and in the evenings he would have a colicky period and cry for hours. My life was a blur of exhaustion and pain."

Jane knew pumping was out of the question because her breasts were far too sore and raw, and she knew that when she went back to work she wouldn't be in an environment where pumping was appropriate. At that point, Jane called her sister, who had nursed two babies, and told her she couldn't go on. "I sobbed and sobbed," she says. "My sister said, 'Jane, give him a bottle of formula, now.'"

The next evening she had her husband give Ben a bottle in the next room. A little while later her husband came in carrying a sleeping Ben and gave her the thumbs up. That night, Ben slept for several hours straight -- and so did his exhausted mom. The difference was in the formula: It remains in Baby's stomach longer than breast milk (which is more rapidly digested by Baby's immature system), and that extra hour or two break from feeding can make all the difference.

Making It Work
When Jane decided to combine breast and bottle, she had no idea how to do so. With her sister's help, she developed her own plan, introducing the first bottle at night, an hour or two after her evening breastfeed. "That way my husband could give Ben the bottle and I could sleep through that feeding," she explains. Then, as Jane neared the end of her maternity leave, she started to introduce another bottlefeed every four or five days, until she was offering a bottle at every other feeding. (According to Dr. Neifert, waiting four to seven days before eliminating another breastfeed will help a nursing mother avoid clogged ducts and even mastitis caused by insufficiently emptied breasts.) "That worked out well," Jane explains. "It gave my milk supply time to adjust, and it gave Ben time to adjust as well. Since I worked from nine to five, I was eventually able to breastfeed first thing in the morning and last thing at night for a long time."

According to Dr. Sargent, Jane introduced the bottle at the perfect point. If an infant is not losing weight, and if you can make it through the first ten days to two weeks breastfeeding exclusively, it may be best to delay supplementation in order to build up your milk supply and let you and your baby get used to breastfeeding. "At this point, substituting a supplemental feeding should make no difference at all in terms of whether or not you're able to keep up breastfeeding," says Dr. Sargent. Waiting a few months to introduce the combo is also okay, says Dr. Neifert: "Every baby adapts differently to new experiences. It may take a little longer for an older breastfed baby to accept a bottle, but it can work."

For many women, combining breast with bottle is simply the best choice for them and their baby. "Doing the combo allowed me to have the best of both worlds," says Jane. "Only then did I experience the bliss of breastfeeding -- after I was able to heal my sore breasts and finally get some sleep."

Donna Jackson writes for many national magazines and has two children.

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