"Breast is best" is a popular refrain—but it's not always true.

By Alex Van Buren
November 28, 2018

When Christie del Castillo-Hegyi, MD, of Little Rock, Arkansas, was pregnant, she was determined to breastfeed her baby. Like many expectant mothers, she had seen human milk described as the “gold standard,” and heard the “breast is best” mantra.

Once her little boy arrived he latched quickly, and seemed to eat well at the hospital. Dr. Del Castillo-Hegyi remembers being sent home with instructions “to exclusively breastfeed and avoid supplementation.” She was warned that her baby would be hungry, but that this was normal—and to just keep breastfeeding.

At home, she continued to breastfeed, but her son cried and cried. When she took him to a pediatrician on the third day of his life, he had lost 15% of his body weight. (Up to 10% is considered normal in full-term newborns.) On day four, a lactation specialist told her she had not been producing milk.

Dr. Del Castillo-Hegyi, an ER physician who had once done research on newborn brain injuries, was too exhausted to realize that her son had hypoglycemia. (The signs can include lethargy, blue coloring, and low body temperature.) She finally gave him a bottle—but three hours later, her baby was unresponsive, and she rushed him to the hospital. He had jaundice (which can be caused by low calorie intake) and was severely dehydrated. “When I saw his labs at the hospital,” she remembers today, “I knew that I had disabled my son for the rest of his life.”

Today, Dr. Del Castillo-Hegyi’s son suffers from a seizure disorder and developmental and intellectual disabilities, which she believes are a result of nearly starving. And Dr. Del Castillo-Hegyi is on a mission to change the messaging the medical community gives women about how to nourish their babies. She is the co-founder of “Fed Is Best,” an organization run by a group of doctors, nurses, and moms who are working to raise awareness about feeding options.  

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“Liquid gold”

In an interview with Health, Joan Younger Meek, MD, chair of the American Academy of Pediatrics Section on Breastfeeding, outlined the current guidelines on breastfeeding: “We recommend exclusive breastfeeding for about the first six months of life, continued breastfeeding after the introduction of complementary solids at about six months, and then ideally a minimum of 12 months total of breastfeeding with no limit in terms of how long mom wants to continue breastfeeding.”

Dr. Meek rattled off the many known medical benefits of breast milk: It has been shown to be more beneficial for infant and childhood growth and development, decreasing the risk of infection, SIDS, diabetes, and some childhood cancers. She says it’s also good for maternal health, with studies showing that breastfeeding lowers risk of breast and ovarian cancer, and type 2 diabetes. (The AAP has plenty of data.)

The “gold standard” and “liquid gold” language used to describe breast milk has not gone unnoticed by moms, particularly those who want to breastfeed but can’t. Virginia Sole-Smith writes about the guilt she felt in her forthcoming book, The Eating Instinct. When her daughter required an emergency feeding tube and Sole-Smith’s breast milk supply vanished, she “still agonized over the decision to stop pumping and switch her over to formula completely.”

Olga Massov of Arlington, Virginia, experienced a similar emotional struggle after she started taking Zoloft for severe postpartum anxiety. She went from being “Daisy the milking cow” to producing a few tablespoons, she says, and switched her baby to formula out of necessity. “I felt so guilty, like I’m doing something horrible to my kid,” she recalls.

Ivonne Thompson also switched to formula because she didn’t have enough milk coming in. The military wife from Houston had desperately wanted to breastfeed her first son when he was born, and remembers her mother-in-law standing over her shoulder as she tried to do so: “You have to breastfeed, and for as long as possible.” After tears, frustration, and a doctor suggesting that she wasn’t making sufficient milk due to prenatal stress—Thompson’s husband had suffered brain injuries in Iraq while she was pregnant—she began giving her baby formula.

On the AAP website, formula makes a few cameos, but usually as a minor player. In the AAP policy titled “Breastfeeding and the use of Human Milk,” it is addressed most directly in a section titled “Contradindications to Breastfeeding”: “There are a limited number of medical conditions in which breastfeeding is contraindicated,” the policy states.

When Health asked Dr. Meek about this, citing women like Massov and Thompson whose breast milk supply was insufficient, she clarified, “Safety is first, and baby being fed is important, whether that ends up being breastfeeding, breastfeeding plus some expressed milk or breastfeeding plus some formula, or [formula] only.”

She warned that we “shouldn’t discard exclusive breastfeeding because a small percentage of babies will get into trouble” (such as excessive weight loss, or jaundice). Nowadays, says Dr. Meek, a full 83% of American mothers start out breastfeeding. There’s less concrete data, however, about those babies who “get into trouble.”

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The risks

Dr. Del Castillo-Hegyi argues that the pressure to exclusively breastfeed and the lack of instruction to new parents to give a baby a bottle when he displays all the signs of hunger are combining to cause real safety concerns for newborns. Though infant mortality rates declined in the U.S. between 2012 and 2015, admission rates to neonatal intensive care units (NICUs) rose. Dr. Del Castillo-Hegyi thinks jaundice is a leading cause of hospital readmission for newborns, which is reflected by a  2008 New York State study that found jaundice to be the number one reason for rehospitalization within 30 days.

“There’s the crazy notion that one bottle or a few bottles could ruin a child on breastfeeding forever, with no regard to the negative and harmful consequences to that kind of advice,” says Dr. Del Castillo-Hegyi. Discharge instructions to new parents include the signs of jaundice and hypoglycemia. But “they don’t tell you that it’s because there’s not enough milk. They don’t tell you to give a bottle—and that’s the problem.”

When she rushed her son—who she and her husband had to force-feed formula to help him regain consciousness—to the hospital, the ICU staffers were unsurprised. “This was a routine thing that happened all the time,” she says.

Dr. Del Castillo-Hegyi is angry. “Not a single pediatrician or lactation consultant or breastfeeding resource ever told me about this life-threatening, brain-threatening, disabling condition that could happen to my child. How is this acceptable in medicine?” She says the most common-sense solution “is to [feed] a child who is showing all the signs of starvation. We won’t give the parents that basic information to save their child’s future and their life. It is an abomination.”

The data on hypoglycemia due to exclusive, failed breastfeeding and the data surrounding readmission rates at hospitals due to jaundice and hypoglycemia, is difficult to tease out. Dr. Del Castillo-Hegyi—who has reached out to the CDC and AAP asking them to better inform parents of the risk of underfeeding newborns—has collated some of her own data suggesting that the problem is more common than those organizations suggest.

There are safeguards in place at hospitals, Dr. Meek told Health, such as daily weight and jaundice checks, to keep babies safe. “There are some babies that need extra attention, they may need supplementation, and we do need to [make] sure they don’t fall through the cracks,” she says. “It doesn’t happen all that frequently,” she added, “but when it does, it’s certainly a serious issue.”

Dr. Meek places the responsibility with the hospitals and doctors. “The pediatrician needs to be following these babies very carefully, and helping develop a feeding plan that’s right for mom.”

Some would argue that parents need more data about formula. Dr. del Castillo-Hegyi thinks her pediatrician and lactation consultant failed her. “We should have been sent to the emergency room” when her baby’s doctor noticed a 15% weight drop, she says.

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The pressure on new moms

The terrible twist of Dr. Del Castillo-Hygyi’s story nearly obscures more everyday examples of women struggling to nurse their babies. For one, it can be painful. Angela Garbes, author of the recent book Like a Mother, remembers a friend saying, “It felt like the baby was latching with shards of glass.”

Stacey Rivera of Birmingham, Alabama, experienced discomfort the first time her son latched. “It was super-painful,” she says, but the hospital staff was “very encouraging-slash-aggressive” about breastfeeding. “Nurses were cheering, ‘Good boy, he latched on so quickly!’” When breastfeeding continued to be painful hours later, and it seemed like her baby wasn’t getting enough milk, she asked the staff for a bottle of formula. “They were really [against] giving it to me,” she says.

One lactation consultant actually blamed her baby for not being unable to nurse properly, and said to Rivera, “I’m so mad at him for doing this to you!” He wasn’t even a day old, Rivera remembers, and “someone could already be mad at him.”

The pressure women feel to nurse their babies, whether it’s external or internal, can sometimes take a mental health toll as well. When a woman is dealing with postpartum depression or anxiety, “the decision about breastfeeding can add to it,” says Robin Muskal, PhD, founder of Postpartum Wellness Counseling in Florham Park, New Jersey. She says breastfeeding comes up frequently in her work with new moms, who often grapple with a sense of loss and failure when they choose not to nurse or have difficulty nursing. “The research points to breastfeeding being superior to formula, but I always encourage whatever will decrease postpartum symptoms—which to me is the priority.”

For many mothers, breastfeeding becomes a time issue. It can consume eight-plus hours of a woman’s day. “I went into breastfeeding naively thinking it’s free,” Garbes says, laughing. “It’s only free if you don’t value a woman’s time.” And without paid family leave (which 87% of American workers don’t have), women aren’t economically supported in their breastfeeding efforts. Garbes gives the example of the mom with a service job who has to go back to work two weeks after giving birth. It’s not a reality for her to pump, never mind to find a place to do so.

The “breast is best” messaging echoed by mothers is an interesting turn in the evolution of breastfeeding in America, Garbes adds. By the 1950s and 1960s, as a culture, we had moved towards formula. Now, she says, many mothers know that breast milk is “the optimal nutrition for a baby.” But it’s not always feasible to nurse, and sometimes it’s just not possible. “The thing where we get into trouble is that not everyone’s body cooperates and does the thing that it’s meant to do. And that can be really hard for people.”

Breast vs. bottle remains a judgmental, tetchy topic. Massov recalls a friend who’d had a double mastectomy being approached by a fellow mother at a “Mommy and Me” yoga class while giving her baby a bottle: “Oh, you chose not to breastfeed?” When informed of the surgery, the stranger slunk away.

Massov sums up her sentiments like this: “If you’re going to be a woman who says, ‘My body, my choice,’ you also have to be pro-choice on whether a woman chooses to breastfeed.”

Alex Van Buren is a Brooklyn-based writer, editor, and content strategist whose work has appeared in The Washington Post, Bon Appétit, Travel + Leisure, New York Magazine, Condé Nast Traveler, and Epicurious. Follow her on Instagram and Twitter @alexvanburen.

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