Breastfeeding Demystified with Maggie Payne-Orton, RN

Last Editorial Review: 7/23/2004

WebMD Live Events Transcript

Are you a parent to be? Do you feel overwhelmed by the conflicting information about whether to nurse or not? Join pediatric nurse practitioner, Maggie Payne-Orton for a frank discussion about breastfeeding.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to the Women's Health Place on WebMD LIVE. Our guest this afternoon is pediatric nurse practitioner Maggie Payne-Orton, RN.

Maggie Payne-Orton, RN, is a pediatric nurse practitioner and a clinical instructor at Emory University's Nell Hodgson Woodruff School of Nursing. She has been involved with Georgia?s Safe Kids coalition and serves as a community advisor to the Wellstar breastfeeding advisory board and as a board member of the Foundation for Medically Fragile Children. As a clinician in rural practice, Maggie provides holistic care to infants, children, and adolescents, as well as lactation consultation to nursing families.

Maggie is a member of the International Lactation Association and the Southeastern Lactation Consultants Association. She received her bachelor's degree in nursing from Florida State University and a master's in pediatric nursing from Emory University.

Moderator: Welcome to WebMD LIVE, Maggie. It is a pleasure having you with us this afternoon.

Payne-Orton: Thank you. I'm happy to be here. I'll start with a little opening statement about breastfeeding . Choosing to breastfeed is one of the most healthy choices a family can make for their new baby. Unfortunately, a great deal of conflicting information about breastfeeding, has been and is being circulated, for example, that most new mothers can expect to have a great deal of difficulty with breastfeeding, and that breastfeeding success is a nebulous goal attained by only a rare and lucky few. These misperceptions have resulted in relatively low breastfeeding rates in our country. About 50 percent of women attempt to breastfeed. 1.8 million woman in our country do not nurse, and this is one of the lowest rates in the industrialized world. Contrary to these popular myths, most mothers can breastfeed. Although we are not necessarily born with the knowledge of how to breastfeed our babies, breastfeeding is an art that can be learned with enough knowledge and loving support. In fact, in cultures where breastfeeding is the norm, breastfeeding success rates approach 100 percent. The benefits of breastfeeding to both mother and infant have been well documented. Infants who are breastfed have less otitis media, diarrhea, and a higher IQ. Among the many benefits noted, breastfeeding mothers are purported to have a better sense of well being and have a quicker recovery after birth. And at this time, I'd like to open the floor to any questions that our audience may have, and hope that I may help a few more women successfully breast feed.

saralg_WebMD: Why do you think most women do not breastfeed?

Payne-Orton: I think there are a variety of reasons, mostly cultural, and stem from an ongoing assault against breastfeeding over the last 100 years. In previous centuries, the very wealthy and members of royalty used wet-nurses, because they felt breastfeeding was below them, like a lower class. And, as we well know, people in cultures tend to want to emulate the rich, and so with modernization, and industrialization, and the ability to mass produce these products, and aggressive marketing directly to physicians in the early part of the 1900's, women gradually began to choose other alternatives to the breast. There's a Victorian influence as well. Some of us are not comfortable exposing our breasts in public, and society views breasts as social icons rather than using them for what they were meant to be used for, to be able to nourish our infants. So the cultural influence is a big part, and coupled with that, the continued aggressive marketing on the part of formula companies, and that most healthcare providers are relatively unprepared to be able adequately counsel and support breastfeeding mothers. So that's part of it. Of course, there are many other reasons, but those are the two biggest impediments I see in breastfeeding.

abigale_WebMD: When would a woman not be able to breastfeed?

Payne-Orton: That's a very good question. We do come across those situations. First, I'd like to address the rare physiological reasons why a woman may not be able to fully support her infant with breastfeeding, or not be able to breastfeed at all. One of those reasons would be a woman who's had breast augmentation or breast reduction, who's had a lot of the ducts cut. she may not be able to produce as much milk as a woman who's not had the surgery, although that's not always the case. The literature says that you may see more difficulty in older women, but anecdotally, I have not seen that. As a matter of fact, there are historical reports of wet nurses that can produce milk into their 80s. Unfortunately, the last physiological reason is that sometimes women who have infertility problems may have a little more difficulty producing milk because there is a hormonal feedback loop involved with breastfeeding. 

The reasons we would recommend a woman not breastfeed are rare. Even for special needs infants that can breastfeed, there are few metabolic problems that may require the infant be on a special formula, such as phenylketonuria. However, some of those infants may still be able to nurse because breast milk has relatively low amounts of phenylalanine. We've probably all heard that, unfortunately, HIV infection is a contraindication in our country. Of late, we've discovered we can significantly decrease what is known as vertical transmission rates, i.e., mother to baby, of HIV if ADT is administered early on to the mother and the baby. There have been no reported cases of HIV in our country from breast milk, but it is found in breast milk. Therefore, we can't take any chances until we know more.

Many infectious diseases that a mother has will not interfere with her ability to breastfeed. As a matter of fact, by the time she herself is aware that she has an infection, she has already exposed her infant, and the infant will benefit from the pass of antibodies that he or she receives from the breast. So it's usually a good thing to nurse when the mom is sick. There are a couple more exceptions to that rule. If mom has active herpes lesions on her breast, she should not nurse until the lesions have resolved. And if the mother has a serious systemic bacterial infection that produces toxins such as toxic shock, or systemic food poisoning, they may produce toxins that the infant can get. Not actual infection, but the toxins. In those cases, once the mom is better, she could resume nursing. Active TB is a contraindication to breastfeeding, but the mother can resume once she is under treatment. The last noninfectious reason that I'm aware of would be chemotherapy and radiation. And after the treatment, 24 hours afterward, breastfeeding can be resumed.

ladyg2_WebMD: Is it advised for women who have had breast cancer to nurse ?

Payne-Orton: There's no contraindication to having had cancer and nursing. The woman should make sure that she's nutritionally ready to have a baby and breastfeed, but certainly it's perfectly fine.

The only thing I didn't mention was drug use. Most of the prescribed medications that a mother is going to receive will be compatible with breastfeeding. Usually there are alternatives, if necessary, or if there are things prescribed that are not compatible, there are alternatives. It's accepted that a mother can have one to two drinks a day if breastfeeding, and we usually advise them to pump and dump. In other words, hold one nursing after having wine, then they can resume nursing. Many of the illicit drugs are transmitted in the breast milk, and of course, there's a concern of whether the mother can take care of the infant if she's using illicit drugs. So there's a lot more involved than whether she should breastfeed.

abigale_WebMD: What exactly is a wet nurse?

Payne-Orton: They were actually paid women who generally lived in the home of their wealthy employers and breast fed their infants for them. They usually had higher social standing than where they came from, so it was a desirable occupation for some women. But unfortunately, it sometimes led to women abandoning the infants that they had to allow them to take this occupation. There's a little informal friendly nursing that goes on, where close friends may nurse each other's infants. That's widely done in other cultures, and somewhat seen in our culture, although it's probably fairly taboo, so you may not hear a lot about it. An interesting anecdote I heard, but people have heard of nipple confusion.. There was a case of an adoptive mom who wanted to initiate breastfeeding in a six month old infant that she'd adopted, and the infant took right to the breast from this adopted mom. She was totally in shock, because she thought this baby had been formula fed for six months, and thought she'd have nipple confusion. Upon further investigation, she spoke with the foster mom that had been rearing the infant for those six months, and lo and behold, she'd been nursing the infant. There was no nipple confusion, because the baby had always been breastfed.

ladyg2_WebMD: How long should you wait if the baby will not drink?

Payne-Orton: Could you clarify your question for me?

Moderator: As we are waiting for a response, we will go move on

saralg_WebMD: What kind of lotion is safe to use on your breasts when you are breastfeeding?

Payne-Orton: Lanolin can be used if you have irritation of the skin around the nipple. It's pesticide free lanolin. Unfortunately, I think it's been seven years ago, there was a scare because they'd found some insecticide in the lanolin, so insecticide free lanolin. Also, if you do a little manual expression, and express some breast milk and rub it around the breast, it has white blood cells in it and can help prevent infection. Other than that, a moisturizer that's hypoallergenic, like Lubriderm, it doesn't have any scent. But they do want to try not to put it around the aereola in the nipple area, because infants love smells, but not the kind of smells we like. They like the smell of mom, the smell and taste of breast milk, the smell of amniotic fluid. That's one of our problems in our society. We want to get everyone cleaned up after birth, and that may confuse the infant, so the infant may not as readily go to the breast.

ladyg2_WebMD: How long should you try to breast feed - a few days after birth? Longer? And if the baby doesn't drink the milk when should you decide to move to formula?

Payne-Orton: AS you are well aware, I'm a big proponent of breastfeeding. However, I'll quote my mentor, Amy Spangler, who is the past president of the ILA (ILA = International Lactation Association). And she says, " When you are talking about breastfeeding, rule number one is feed the baby. And rule number two is see rule number one. So, the infant's survival is above all our main goal, and a starving infant isn't going to breastfeed well, either. They have to have caloric reserves to be able to nurse. Sometimes, if one of the problems I mentioned is interfering with breastfeeding, or the baby has been given a bottle early on and they have nipple confusion, breastfeeding may not be going as well as we'd like. And in these instances, the mother should begin pumping, and it's pumping fairly frequently, five or six times a day. This will hopefully continue to stimulate her nipples and promote breast milk production. If an infant has lost more than ten percent of their birth weight, and not gained it back within ten days, that is, is not back to birth weight, we should be watching that infant closely and intervening, and pumping should be considered. If an infant is two to three days old and is not having four poopy diapers, or not showing urine output, then we need to intervene. There are a variety of things we can do. Hopefully we have got the mother pumping, and we can give pumped breast milk and/or formula via a variety of methods.

LadyG2 didn't say whether it was a problem with an infant taking the milk, or the mother producing it, so I can't give all the information I'd like. But we can try a supplemental nurser, and you can buy an S&S nurser. And that's where they hang a bag with either pumped breast milk or formula, and there's a tube that is taped to the breast, and the baby stimulates and suckles the breast, and at the same time the baby gets nutrition as well as positive reinforcement that they can get food from the breast. The problem to watch with that is sometimes they are smart little creatures, and they'll grab the tube and suckle the tube. You want to discourage that. Another alternative is finger feeding where you use a little syringe with a tube connected. The tube is taped to your finger, and you put your finger in their mouth with your nail side down to help them learn to suckle. Sometimes this can help them learn to open their mouth like they're supposed to, and their tongue down. Then another method is cup feeding, and you use a tiny cup, and can also do this with a teaspoon. You hold the infant upright, and help teach the infant to keep their mouth open wide and tongue down. The key is to use a variety of methods, so that they don't decide, for example, that they just want to be fed from the finger. You're still giving the infant the nutrition they need, and teaching them, hopefully with the help of a lactation consultant how to properly open their mouth, and you avoid confusing them with a nipple which has a totally different type of suck than suckling from the breast.

Moderator: In your opinion, at what age should a child be weaned?

Payne-Orton: Great question. I knew someone would ask that. Although there is no magic number for weaning age, I will tell you that internationally, the average age is two to four. Of course, that helps with child spacing. In cultures where children are weaned later, they tend to have smaller families, and it's seen as an economic benefit. In our culture, we don't necessarily want to rely on breastfeeding for child spacing.. So, what are the reasons for nursing for a longer period of time? There are several. The infant continues to receive passes of antibodies from the mother for as long as they're nursing. They also continue to have that wonderful bonding time with mom, that special time. And up until the age of two, they continue to have tremendous brain growth. So most importantly, you're feeding that brain with human specific fat that will result in myelinization of the nervous tissue. So I encourage people, if they're comfortable, to nurse until two, or a little older. But it's not a sexual act, it's not psychologically harmful to the infant, and may continue to be a nice bonding experience for mother and baby. But many people aren't culturally comfortable with it, and that's okay. If you're not, try to nurse until one. There's a lactation consultant I know, who is a big proponent of breastfeeding, and is wonderful. She has two grown children. She tells the story that her daughter breastfed until two, and her son breastfed until 15 months. The reason for this "early weaning" on the part of her son was because of his behavior. Her daughter was very polite breastfeeder, and would quietly request to nurse, and it was nice quiet time for her and her daughter. Whereas her son would usually choose a crowded party to run across the room after her, and cry out, "Boobie, boobie," so, she weaned him a little earlier.

DrRose_WebMD: What do you say to someone who says, "I had formula, and look, I turned out fine"?

Payne-Orton: I think that's an excellent question. I tell them that we know a lot more about the value of breastfeeding than we ever did before, and that we're still learning about all of the wonderful things found in breast milk. First of all, as the healthcare provider, it would be inappropriate for me to withhold information that could help their child self-actualize to be the best person they can be. What I try to do is let them know what we know now, such as the benefits to the mother, which are she has less of a risk of premenopausal breast cancer, less of a risk of ovarian cancer, even if she only breastfed for a short period of time. She will have less osteoporosis, and that she's going to return to her prepregnancy state more quickly if she breastfeeds. In addition, she may save $700 to $1,000 a year depending on the formula that she'd be purchasing, and that can go into a college fund. She won't have to get up in the middle of the night to make a bottle. It's not a silver bullet for everything, but usually we won't see them in the pediatrician's office as often for illnesses, the infant. We see less wheezing, especially under four months. Two month olds are the ones at risk for apnea, if they wheeze. And they also are at less risk for SIDS (sudden infant death syndrome), less otitis media, and less diarrheal illnesses, and consequently less hospitalization. 

I try to explore with them what are the reason they don't want to breastfeed. Some people have the misperception that they have to expose their naked breast to the world. They don't . There are many ways to breastfeed discreetly. Lastly, I talk about the fact that they do have a higher IQ. Even if their IQ is a little higher, maybe her mom went to a state school, but her kid will get in to Harvard. Who knows? A few points on an SAT can make a big difference. Having said all of that, there are some mothers in our culture who do not feel comfortable with breastfeeding, and will not, and if we've done our job to give them honest, accurate information and support, and they choose not to breastfeed, the best thing to do is say the serenity prayer, and continue to be a partner with them in the care of their child.

abigale_WebMD: I have heard that breastfeeding makes it harder to lose weight after pregnancy. Do you believe that this is true?

Payne-Orton: That's actually not true. It's not documented scientifically and empirically (what I've seen in practice), but being in practice for nine years, I haven't seen that. As a matter of fact, I've been concerned with mothers getting a little too thin with breastfeeding. If you need 500 to 750 extra calories a day to be able to support breastfeeding, and you're not taking it in, you may lose too much weight, but I have not seen that as a problem. I'm sure there are exceptions to that rule, but in general, if you eat healthy, and try to establish a regular exercise routine, like everyone's been telling us for years, you should be able to lose the pregnancy weight and breastfeed successfully.

ladyg2_WebMD: Is it true that babies can nurse and breathe at the same time for a while? And why is that and at what age do they lose that ability?

Payne-Orton: That's an interesting question. It has to do with the fact that infants are obligatory nose breathers. Now, an older child can nurse and still continue to breath through their nose, but an infant, almost to a fault, will not open their mouth to breathe. That's why when infants get stuffy noses, they get frustrated and don't nurse as well. Infants, first and foremost, have a drive to live. If they cannot breathe and eat at the same time, they will not stop breathing, but rather they will pull off the breast to be able to breathe, unfortunately sometimes with the nipple still in their mouth. But the breastfeeding position that an infant should have is square on the breast, chin tucked in, with the nose lightly resting on the breast. You should be able to hear the sound of them breathing in and out through their nose while they're nursing.

The seven recommendations for highly effective breast feeding are: 

1 - Knowledge is power. Prepare ahead of time, attend classes, and read, read, read about breastfeeding.

2 - Think positively. Most women can breastfeed. Find positive support, role models, get your significant other involved,

3 - Beware of the traps, the things that interfere with successful breastfeeding, such as separation from your infant for prolonged periods of time, artificial nipples, strict feeding schedule, i.e., babywise; health care personnel or well-meaning family and friends who may ill advise you.

4 - Seek out a family friendly birth place, and ask about their lactation support. Seek out health providers who are knowledgeable and support lactation, and don't just give it lip service.

5 - Seek out health providers that are family friendly.

6 - If you're a working mother, stand up for your womanly right to breastfeed, just like Tony Blaire's wife. Or pump at work in a clean comfortable environment, not in a bathroom.

7 - Know that you are giving your infant human specific vital fluid that can never be duplicated or replaced. Any amount that you give to your infant is enormously beneficial.

Here are some references for further reading that I recommend to families who are breastfeeding or thinking about breastfeeding: The Breastfeeding Answer Book, by La Leche for practical breastfeeding advice; Breastfeeding, a Parents' Guide by Amy Spangler, a shorter version of the above that is full of excellent advice for new parents; Our Babies - Ourselves by Meridith Small for an anthropologist's view on the origins of parenting practices and breastfeeding; Milk, Money and Madness by Baumslag and Michels for information on why to breastfeed and the culture and politics of breastfeeding; Breastfeeding. A Guide for the Medical Profession by Dr. Ruth Lawrence for health care professionals.

Moderator: The medical opinions given by Maggie Payne-Orton, RN, are hers and hers alone. If you have specific questions or are concerned about your health, please consult your personal physician.

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