Foremilk and Hindmilk; Myth or fact and why should we care?

Lillian asked: “I learned in the CLC course that there is no such thing as foremilk and hindmilk for changes in nutritional content. I have also read and heard from IBCLCs that hind milk has a higher fat and calorie count with less lactose compared to foremilk. I am also aware that some cultures who nurse more frequently than the US culture of 8-12x/day would not necessarily “empty” the breast or access the hindmilk. These cultures still produce healthy and typical kids. The foremilk/hindmilk concept has come up regarding pumping mothers in the NICU where weight increase has been an issue at my place of work. However, the regiment an IBCLC recommended seemed very tedious. Additionally, I know the nutritional content of preterm breastmilk is different than term breastmilk and is baby specific for that feeding dyad. Would you be able to point me in a positive direction to further understand if foremilk and hindmilk differences exist and how this may impact the breastfeeding dyad or if this is a myth?”

So let’s dive right in with a discussion about the differences between foremilk and hind milk.  It is absolutely NOT A MYTH.  I am not surprised when I hear people tell me that they doubt there is a difference in breastmilk from the beginning to the end of the feeding, I used to say the same thing.  “What? Is there some kind of barrier that is removed half way through the feeding?”  I am a little embarrassed to admit I said that to many a patient over the early years of my career.  Well there is plenty of evidence to suggest that there is a difference between the milk released at the beginning of the feed and that released at the end of the feed.  The primary difference is in the fat content.  The difference is so very striking and predictable that it is a common scientific method of measuring the amount of milk remaining in the breast, the method is called “The Creamatocrit Method”.  The group that uses this method the most is the Hartmann group out of Australia.  If you pull any study from that group regarding milk volume you will find reference to that well documented phenomenon.  My favorite article on the basics is Kent, 2007 “How breastfeeding works” published in The Journal of Midwifery and Women’s Health 52(6).  It is older and doesn’t go into detail about the MER, but it is a straightforward discussion on most clinical breastfeeding questions.  It is easy to understand if you think of simple fluid dynamics.  If you mix sand and water in a pail allow it to settle and then start pouring, the first thing that will come out is the water, as you get to the end of the bucket you will get more sand and eventually, it will be wet sand that comes out and very little water.  The same is said for breast milk.  The first milk ejection (MER) reflex is almost entirely water and lactose, I describe it as “skim milk” or “fat free milk” It is approximately 4% fat.  The second MER is like whole fat milk, mostly water, but more fat.  The third MER is a milk shake, whole fat milk and high fat ice cream, and the last is almost entirely fatty ice cream, a little more than 12% fat.  In that study they cite another Hartmann lab study: “Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeeds and fat content of breast milk throughout the day. Pediatrics 2006;117:e387–95” here they document the findings specifically.  If you are interested in a full discussion, that is probably where you should start.  For reference values, Khan, Prime, Hartmann and few others did an interesting study looking at 24-hour nutrient intake for the Journal of Human lactation in 2013 (Volume 29(1)) where they used the fore milk and hind milk samples of mothers to extrapolate an average fat, lactose, and protein content of each feeding and the test weights of the infant and calculated the 24-hour intakes.  They, again demonstrated that the milk was lower in fat before the feeds (average 32 g/L) and higher after the feed at 56 g/L.  They found no difference in the lactose or the protein in the foremilk and hindmilk samples.   All that said, the authors also point out that the average baby tends to balance out feedings and that there is no real difference from feeding to feeding when you look at 24-hour intakes.  So you could say that there is very little clinical value in looking at foremilk/hindmilk as a phenomenon for the average baby.  Of course, it isn’t “the average baby” that a lactation consultant sees.  We are the experts of infant feeding and are usually only called on when there is a problem.  A baby who isn’t growing well, has green frothy poop, and eats for less than 10 minutes at a feeding, has all the hallmarks of a baby eating a low-fat diet due to inadequate time spent on the breast.  That is where a firm understanding of the difference between foremilk and hindmilk will be most valuable. 

As for feeding preterm infants.  I don’t have much experience in that topic, but what knowledge I do have comes from the excellent work of Paula Meier.  A decent review of breastfeeding management written by her is Meier, Write, and Engstrum (2013) Management of Breastfeeding During and after the Maternity Hospitalization for Late Preterm Infants. Clinics in Perinatology; 40, 689–705.  It is a good over view of the entire feeding problem for preterm infants.  While I was putting this note together, I also found a very promising review from Meier, Johnson, Patel, and Rossman, published in Clinics in Perinatology 2017; volume 44 (1) pg 1-22.   It is called “Evidence Based methods that promote human milk feeding of preterm infants: An expert review.  It looks very promising, but I don’t have time to read it before I send you this email.  I advise you to pull it and look into it. 

I hope that helps and answers a few questions for you. 

Someone asked me if it was safe to breastfeed a baby after receiving Omniopaque 350 contrast dye for a CT scan.  The short answer to your question is that it is isn't well studied, but my gut tells me that there is very little or no harm to the infant via breast milk and here is why.
Omnipaque is an iodine based radiopaque contrast dye used in the diagnosis of vascular conditions (like pulmonary embolism).  It is usually injected into the spinal fluid or the blood stream.  It has a moderate/large molecular weight at 821 Dalton and is very poorly bound to protein.  It is a pregnancy class B drug (which means it is more safe to the unborn child than most drugs).  It is "very poorly absorbed from the gastrointestinal tract".  It is rapidly excreted through the urinary system with 99% being excreted unchanged in 24 hours. Here is why I think this drug is okay.
1) The molecular weight of 821 means that it is unlikely to pass into the breast milk since it is a large molecule and may be too large to enter the milk in the first place.  Molecular weight isn't the only thing that dictates passage, but unless it is bound to a protein and carried actively into the lactocyte it is unlikely to enter the milk (its just too big to get in easily).
2) It is unbound to protein, now that generally means that there is free drug in the blood stream and thus it is more easy to leak into the milk.  if that was all I knew about this drug, I would worry.  But it isn't.
3) The oral bioavailability of this drug is only 0.1-0.5% that means that almost nothing is absorbed through the stomach. Now here is an EARTH SHATTERING idea, Breast milk is an oral drug.  That means that anything that makes it into the breast milk has to be absorbed through the gut to enter and harm the baby.  In the case of this drug, almost nothing is absorbed in the gut.  IF any omnipaque entered the breast milk it would simply pass through the stool undigested, un-absorbed, and without harm.  When I first heard Dr. Thomas Hale say that in a conference it literally blew me away!  I had never thought of that before.  So as a general rule, we give people IV drugs because they can't pass through the gut very well (Morphine, Gentamycin, IV Contrast dye).  So an IV only drug is almost always perfectly safe.  Even if 100% of the drug entered the breast milk less than 1/2% of that dose would enter the baby to be excreted by the kidneys.  That is nothing.
4) A class B drug.  That means that there is no evidence of harm to the developing baby.  If you can give this drug to a pregnant mother without risk (and those kidneys are VERY premature) then I am confident that it won't hurt the newborn. The only exceptions to that rule are drugs that are sedating (narcotics and such) the unborn baby isn't breathing, so respiratory depression or sedation wouldn't harm him but it can harm a newborn who is responsible for breathing on his own.
5) It is rapidly excreted in the kidneys, that means that if anything entered the blood stream, what little entered would be rapidly cleared.  It wouldn't accumulate in the blood, the fat, or any of the baby's organs.
6) It is safe to use the drug on children.  There is no restriction of this drug for pediatric use.  The FDA flier doesn't specifically state it is safe to use in newborns, but it clearly shows that it is safe for pediatric use.  If there was a restriction the FDA would report that, and they don't.  If you can inject it into a newborn without risk of injury, you can probably allow it to go into his mouth without injury.

So yes, while I accept that it is poorly studied, I can't see any reasonable reason to worry about this drug harming the newborn.

Tom
 References:  Hale and Hartman (2007) Textbook of Human Lactation (chapter 24 "The transfer of medications into human milk).
FDA (2016) Medication information - Omnipaque.  Retrieved from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/018956s095,020608s031lbl.pdf on 2 Feb 2017.

Last week I got a letter from Erica asking my advice on re-establishing breastfeeding for her 4 month old who stopped at six weeks due to GERD. This was my very long response. In a nutshell, if you have stopped nursing but actually want to breastfeed your baby, YOU CAN!! This post will help you achieve your goal.

The vast majority of women who wean prematurely do so out of fears of inadequate milk supply. New mothers are in an incredibly vulnerable state and tend to blame every hiccup, every cry, and every fussy baby on herself and her milk supply. This often leaves new mothers feeling that they are failures because they were unable to breastfeed their babies and guilty because they are giving their baby formula which is known to increase the risk of countless childhood diseases. Fortunately, the perception of inadequate milk supply is often more of a misperception rather than a physiologic fact. That means that most women who wish to breastfeed after weaning can relactate and resume breastfeeding with the proper support and coaching.

Most women who have prematurely weaned and wish to relactate are good candidates for success. There is a small pool of mothers who find breastfeeding nearly impossible due to physical factors. Those with developmental abnormalities affecting the glandular tissue of the breast, endocrine disorders (disorders of the thyroid or pituitary gland), mothers of premature infants, and mothers who have never nursed may find re-lactation difficult. Most women however are healthy, have healthy, term infants, and are likely to succeed, particularly if they have successfully nursed in past. Indeed there is even evidence suggesting that breast development during the first pregnancy and breastfeeding attempt is enhanced following the birth of a second child, even if the mother did not successfully breastfeed her first child.

Keys to successful re-lactation include:

Realistic Goals: Re-lactation can be time consuming and stressful and it may take several weeks to reach exclusive breastfeeding. While many women can successfully re-establish exclusive breastfeeding there will be women who are unable, for myriad reasons, to exclusively breastfeed. I encourage women to set realistic goals on how long it will take to achieve success and what success will mean to her but to never give up. After all, a mother who is partially nursing while supplementing is still breastfeeding her child, whereas the mother who quits entirely is not breastfeeding at all. Success in re-lactation however, must be determined by the goals set by mothers, not lactation professionals.

Support: Lack of support leads to lack of confidence; lack of confidence leads to infrequent suckling; infrequent suckling leads to breastfeeding failure. All three are associated with less successful re-lactation. Breastfeeding mothers who suffer with feelings of inadequacy due to milk supply problems must be supported by their family and social groups if they hope to successfully re-lactate. Breastfeeding cannot be one of the many chores a woman must do each day; it must be the priority of the entire family. Mothers who find themselves trying to work pumping, SNS use, and breastfeeding into their already full schedule will often find themselves unable to overcome the challenges of re-lactation and will fail.

Nipple Stimulation: There are several techniques for nipple stimulation, perhaps the most successful is direct infant suckling. However the mother can augment that with hand expression, breast massage, warm compresses prior to stimulation, and mechanical pumping. Some studies have shown that combinations of these techniques enhance success.

Milk Removal: Since the breasts synthesize milk based on the degree of emptiness, breast drainage must be a part of nipple stimulation. The mother may find that a period of trial and error is needed to determine the best strategy for breast emptying (infant suckling, hand or pump expression, etc…).

Galactogogues (medications or herbal supplements that increase milk production/synthesis): The two most common medications used to augment milk synthesis are Metaclopramide (Reglan) and Domperidone. Both are anti-nausea medicines which increase Prolactin production. Unfortuantely, scientific evidence demonstrating the effectiveness of galactogogues is weak. Both Reglan and Domperidone have been shown to increase Prolactin levels and milk production. However, the studies demonstrating this, lack credibility in the scientific community. As such, it is important that women who take these medication understand that while they may be helpful, they are by no means a magic bullet that will increase milk synthesis. The evidence in support of Mother’s Milk Tea, Fenugreek and Milk Thistle (all common herbal galactogues) is even more questionable. Given the subjective way that milk production is measured (see previous articles on Sage Homme), it is possible that many galactogogues work through the placebo effect rather than by actually increasing activity at the molecular level. That said, the point is moot; the goal of relactation is to empower a mother to breastfeed her child and the exact physiology behind her success is not as important as her success. I therefore support safe and responsible galactogogue use under the supervision of a competent IBCLC.

Oxytocin (OT): OT is the hormone that causes the Milk Ejection Reflex (MIR), also known as the “Let Down” effect. OT surges in response to nipple stimulation, and during pleasurable experiences (skin to skin contact, infant snuggling, and affectionate attention from a loved one). It is therefore, no surprise that stress, anxiety, fear, and pain all decrease OT release. OT is also released due to conditioning responses, meaning that OT release is enhanced when mothers do things that remind them of breastfeeding. For example if you always sit in the same chair to breastfeed, the act of sitting in that chair will increase your likely hood of having an OT surge. I often suggest that pump dependent mothers cover their breasts and pump with the baby’s blanket. Not only does this hide the pump and keep mothers from stressing over the actual movement of milk, but it also triggers a conditioned response to breastfeed due to the smell of the baby on the blanket. The important thing about OT is to relax and enjoy the time spent breastfeeding, and as much as possible, the time spent pumping, hand expressing, massaging the breasts. Synthetic OT is available in some areas through compounding pharmacies and can enhance the let down response.

So, in a nutshell, yes, you can relactate but you and your loved ones have to commit to it. The key physical factors needed for relactation are nipple stimulation and milk removal. I can’t stress enough that in order to enhance the success of nipple stimulation and milk removal the mother must be confident in her abilities, comfortable and relaxed while nursing, and must have realistic goals. The mother must be supported and able to prioritize relactation. I strongly recommend that any mother having difficulty with milk production see a lactation consultant immediately to avoid weaning however, weaning does not have to be permanent. If you have stopped nursing and want to relactate, you can.

In the words of Winston Churchill “Never, Never, Never, Never, Never, Give Up!” You can do it!

References:
Thorley, V. (2012) Induced Lactation and Relactation. In Mannel R., Marten, P.J. and Walker, M. Core Curriculum for Lactation Consultant Practice 3rd Ed. Jones and Bartlett Publishers. Burlington MA.
Academy of Breastfeeding Medicine Protocol Committee. (2011). ABM Clinical protocol no. 9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (first revision January 2011). Breastfeeding Medicine, 6, 41-49.
Agarwall, S., & Jain, A. (2010). Early successful relactation in a case of prolonged lactation failure. Indian J of Pediatrics, 77(2), 214.

Cow's Milk Protein sensitivity and Buffalo Milk

Jamie asked me, what is perhaps the most interesting question I have ever been asked. 

“Do u know of any cross reaction between breast milk protein, cow milk protein and buffalo milk protein.”

As it turns out she has a client who is traveling to a country where drinking buffalo milk is rather common and the client has a nursing infant who is sensitive to cow’s milk proteins.  She wanted to know if buffalo milk would be the same.  I have never in my life considered buffalo milk and so it took some digging.  I was interested to discover that in general buffalo’s milk has a lower risk of causing problems through breast milk than does cow’s milk and that Indian buffalo bred for dairy production are better than wild-type buffalo (Sodhi et al., 2012).  I was also turned on to a new interest, and that is the study and diagnosis of Cow’s Milk Protein Allergy (CMPA) and Cow’s Milk Protein Insensitivity (CMPI).  It would appear that “lactose intolerance” is frequently over diagnosed when in fact the real problem is A1 β-casein intolerance.  Who knew?  Now I do, and I will share this with you.

In a rather complicated and technical paper on the specific components of milks commonly found in India, Islam and colleagues analyzed the chemical make-up of Buffalo, Holstein hybrids, Red Chittigong cattle (RCC) and “indigenous cattle” that are commonly found in India.  They found that Buffalo milk and that of the RCC was nutritionally better than Holstein cow’s milk (HC).  When compared to HC, buffalo and RCC are higher in fat and protein and lower in A1 β-casein (Islam et al, 2014).  So to answer the question, the breastfed infant is likely to be fine if his mother drinks buffalo milk while outside the U.S.  But that wasn’t enough for me.  I, like you, had never herd {VBG} of A1 β-casein, so I had to look it up and figure out why it mattered. 

As it turns out there are two primary milk protein in mammalian milk, particularly among dairy animals.  They are A1 β-casein and A2 β-casein.  A1 β-casein (A1 from now on please) is the primary source of irritation in non-human milk intolerance and it is predominantly found in European cattle breads (Holstein and other “black and white” cows).  A2 β-casein (A2) is not known to cause milk intolerance (Pal, 2015).  A2 comes from Asian, African, and American cattle breeds that are brown i.e. Jersey cows and other “southern breeds” (Snowville Creamery, 2016).  That may be enough for many of you out there but if you are really interested, I will carry on.

So, A1 has a very interesting effect on the human gut.  Upon entry to the GI system A1 proteins activate BCM-7 (the real bad guy) and that protein stimulates the opioid receptors in the gut (Pal, 2015).  That’s right, I said opioid receptors. Some of you are wondering how milk can be a narcotic (it isn’t).  The opioid receptors in the brain are responsible for decreasing pain, but those found in intestine simply slow down the passage of chyme through the GI tract.  When things slow down in the gut those contents begin to irritate the lining for the intestine and you get constipation, bloating, pain, and diarrhea.  Does sound familiar to any of my “lactose intolerant” friends out there?  In infants it will also frequently cause vomiting and bloody stool.  Any lactation consultant worth her salt will tell you to remove all forms of dairy from your diet for at least 2-3 weeks to allow the baby’s GI system to heal.  If symptoms go away you know what it is and how to treat it (don’t go back to dairy).  But after reading this I hope that you will consider trying to find A2 milk and give that a try since it just might work. 

Another thing I found while researching this article was cow’s milk protein allergy (CMPA) which is far more serious than insensitivity.  It is an actual allergic reaction to cow’s milk protein (A1 and/or A2).  It usually starts with a rash in the first month of life (or the first month of formula feeding) but can also present with GI illness, and even respiratory problems leading to anaphylaxis.  In the western world 2-3% of infants will be allergic to cow’s milk protein for the first three years of life.  Oddly enough, babies tend to grow out of this allergy and 85-90% of them will be allergy free by age 3 (Host & Halken, 2014).  What was maddening for me as a lactation consultant was that while researching for this post I found several articles on the diagnosis and treatment of CMPA the authors never once recommended putting the baby on breast milk to treat or prevent the allergy.  In their excellent article “Cow’s milk Allergy: Where have we come from and where are we going” Host and Halken offer several possible treatments for CMPA.  First they offer changing to extremely hydrolyzed formula (eHF) but admit that it is rather biter and unpalatable making it difficult for an infant to tolerate and rather expensive making it hard for the parents to tolerate (2014).  Then they offer exposure therapy through an new treatment modality known as OIT (oral immunotherapy) in which they offer the infant small but ever increasing doses of the allergen over a period of time gradually making the infant immune to the allergenic effects, but they again concede that it is risky and that “a subset of patients have developed significant side-effects.”  Further they suggest that the results are transient and will fade when you stop exposing the infant to the allergen.  Finally, they recommend injectable IgE therapy with omalizumab (try saying that five times fast) (Host & Halken, 2014).  I shudder to think of the poor infant having routine injections of any medication but particularly one that will attempt to suppress the immune system at such a young age.  Why, we are left to wonder, does the author not suggest switching to human breast milk rather than doing all of this to the poor infant?  But that is a topic for another day. 

So there you have it.  If you have a baby who is sensitive to cow’s milk he is most likely sensitive to A1 β-casein and not lactose intolerant.  The primary treatment for cow’s milk protein sensitivity and cow’s milk protein allergy is the same, remove the cow’s milk from the baby’s diet.  Either remove it from the mother’s diet, effectively removing it from the breast milk (not well studied I have to admit) or if he is on artificial milk supplements (AKA Formula) then take him off the formula in favor of either breast milk or eHF (yuck!).  Finally, if you happen to have a supply of buffalo milk, give it a try, you might be happy with the results. 

References:  

Host, A. and Halken, S. (2014) Cow’s Milk Allergy: Where have we come from and where are we going? Endocrine, Metabolic, and Immune Disorders – Drug Targets.  14, 2-8.

Islam, M.A., Alam, M.K., Islam, M.N., Khan, M.A.S., Ekeberg, D., Rukke E.O., Begarud, G.E. (2014) Principal milk components in Buffalo, Holstein Cross, Indigenous Cattle and Red Chittagong Cattle from Bangladesh.  Asian Australas Journal of Animal Science V27, 6: 886-897. http://dx.doi.org/10.5713/ajas.2013.13586

Snowville Creamery (2016) About A1 and A2 beta-casein in cow’s milk.  Retrieved 18 Feb 2016: http://www.snowvillecreamery.com/a1-and-a2-beta-casein-in-cow-milk.html

Sodhi, M., Mukesh, M., Kataria, R.S., Mishra, B.P., Joshii, B.K. (2012) Milk proteins and human health: A1/A2 milk hypothesis. Indian J Endocrinology and Metabolism.  Sep-Oct; 16(5): 856.  doi: 10.4103/2230-8210.100685

Pal, S, Woodford, K., Kukuljan, S., Ho, S. (2015) Milk Intolerance, beta-casein and lactose. Nutrients, 7:7285-7297.  doi:10.3390/nu7095339

PCOS and Breastfeeding

Recently Deseree, a third time mom with a history of PCOS, asked a question about how to avoid a milk supply problem when her next baby is born.    To summarize, she has attempted breastfeeding twice, both times her breastfeeding started out well with initial physiologic engorgement, her milk “came in” and the babies were eating well.  At two weeks old however her babies were not gaining weight.  She is now 37 weeks pregnant and wants to know what she can do to prevent a third disappointing breastfeeding experience.

First it is important to say that what Deseree needs most is a supportive and knowledgeable lactation consultant who can complete a full history and breast exam to rule out the most common problems.  Since the problem happened for both of her children I will assume that the issue is maternal and not a newborn issue, but that is just an assumption.  Deseree, it is important that you first look for the low hanging fruit; are you eating a balanced diet (Vegans, women with absorption issues, gastric bypass patients all are more likely to have an infant with slow weight gain).  Next I would like to do a complete physical exam to rule out breast issues, hypoplastic breasts or those with inadequate glandular tissue would also raise a red flag.  Finally, I think it is important to ensure that breastfeeding begins on a positive note with as few barriers and booby traps as possible.  I always recommend prolonged, uninterrupted skin to skin contact until breastfeeding is well established.  Assuming that all of the easy fixes have been addressed, I think the most likely source of your trouble is polycystic ovary syndrome (PCOS). 

Polycystic Ovarian Syndrome is an endocrine disorder that affects up to 15% of women, it is marked by irregular menses, infertility, recurrent pregnancy loss, facial hair, acne, and a host of other interesting symptoms brought on primarily by excessive androgen production and insulin resistance.    Of course anything powerful enough to cause all of those hormonal disturbances in a non-pregnant woman can certainly wreck havoc on a breastfeeding mother.  There is good evidence that PCOS can lead to breastfeeding problems, particularly problems with inadequate milk supply.  The best source of information I have on this problem is Diana West and Lisa Marasco’s excellent book “The breastfeeding mother’s guide to Making More Milk” (McGraw-Hill, 2009).  This source has a comprehensive section on PCOS and how to help improve breastfeeding success.  There is a medicine that your doctor can prescribe called Metformin.  This drug helps the body process insulin which will, in turn improve milk supply.  I recommend starting it as soon as possible and begin pumping at 38 weeks to stimulate breast growth. 

If your doctor is unwilling to prescribe metformin, or if you want to try a “double whammy” you can also take a couple of herbal supplements.  Goat’s Rue (actually contains a precursor to Metformin called Guanidine) has been shown to increase milk production in dairy animals by 35-40% and stimulate breast growth.  Goat’s Rue can be taken as a tea (1 tsp of leaves steeped in one cup of water for 10-15 minutes 2-5 times a day), a tincture (there are several available doses, you will need to get with an herbalist to find the best dose and brand available but they range from 1-4 ml up to 4 times per day), or as a capsule from Motherlove taken four times a day).    Another herbal supplement to use in conjunction with Goat’s Rue is Marshmallow Root.  Marshmallow root is believed to enhance the effectiveness of Goat’s Rue and may enhance the richness of your milk.  It can also be taken in a tea (1 tbsp in 5-8 ounces of cold water allowed to stand for 30 minutes), a tincture (1-4 ml three times a day), or a capsule 2-4 capsules three times a day).    Consult an herbalist for the best product available to you. 

Finally, if it comes to having to supplement your baby it is vital to remember that breastfeeding does not have to be ALL OR NOTHING.  You may find that your baby needs a little more than you have to offer, but if that becomes necessary I recommend using a supplemental nursing system (SNS) which will allow your baby to continue to breastfeeding (thereby stimulating milk removal, breast growth & development, and increasing milk supply) while also encouraging your infant to achieve robust growth.  I often use the analogy of walking when I talk about breastfeeding difficulty.  No parent would ever accept that their baby just didn’t or couldn’t walk.  Rather, a five year old who is struggling with walking is offered physical therapy, braces, assistive devices, walkers, crutches, and every manner of surgery and medical treatments.  Some children actually need help with walking and they get it.  No mother would simply say “My baby didn’t want to walk, so I bought her a wheelchair.  What’s the benefit to walking anyway?”  But replace “walk” and “Wheelchair” with “Breastfeed” and “Formula Feeding” and you a lactation consultant hears that almost every day.  No, it doesn’t have to be ALL OR NOTHING, if it isn’t perfect, it is still breastfeeding. 

I’m sorry that it took me this long to reply, if you have any other questions or concerns, please don’t hesitate to ask.