THE THIRD IDEAL OF ATTACHMENT PARENTING:
This article was published in two parts, citation information below.
Ang, M. (2006). The Third Ideal of Attachment Parenting: Breastfeeding. In Infanity magazine, April and May 2006 issues.
Much has already been said about the importance of breastfeeding in the pages of previous issues of this magazine. Breastfeeding is also the third ideal of Attachment Parenting. I will not cover topics already covered in this magazine but will instead directly jump to relevant issues that have not yet been addressed within this magazine. Readers who still need convincing as to why breast is best really need to read references ,  and  in my reference list below.
I would first like to address typical issues in our Malaysian context that interfere with and often lead to complete failure in breastfeeding a newborn baby. After that I would like to discuss why so few Malaysians achieve the WHO and UNICEF recommendation that infants be exclusively breastfed for the first 6 months of life with complementary foods being introduced after 6 months and breastfeeding continuing up to 2 years of age at least. Why these recommendations are important are clearly explained with plenty of scientific supporting facts in references ,  and  in my reference list below.
It is important to realize that there are preventable and non-preventable reasons for failure in breastfeeding. This article will focus primarily on those preventable causes in the hope that new mothers will recognize these problems when they face them and know the right course of action to ensure the successful continuation of their nursing of their baby. We will briefly mention some of the genuine causes of breastfeeding failure and how those that genuinely have to resort to bottle feeding can still do so with an AP approach.
Issues leading to failure in breastfeeding a newborn
Unsupportive hospital practices are one of the primary reasons that many mother fail to successfully initiate breastfeeding of their newborn infants. The period immediately after the birth is critical in terms of baby learning to correctly latch on and draw milk from mother's breasts. Baby needs to suckle as often as necessary, to stimulate milk production in mother. Much of this has been explained in previous articles on breastfeeding in this magazine. Government hospitals are typically very good in helping mother begin this nursing relationship properly - the same cannot be said of most private hospitals. Sadly, many private hospital nurses undermine mother's attempts to breastfeed by routinely giving baby infant formula. This practice is devastating as a newborn baby must learn to suckle and draw milk from his/her mother's breast but infant formula from a bottle requires very little suckling effort on the part of the infant - what happens then is that baby never learns to suckle properly, and when this happens, mother's milk production is not stimulated and eventually dries up. Even if baby is not given infant formula using a bottle but using a spoon instead (so that suckling reflex will not be affected) the very act of filling baby up with formula means that baby will not be hungry enough to suckle strongly at mother's breast when the time comes. The end result is the same - mother's milk production is not stimulated and eventually dries up. Most, but not all, Malaysian private hospitals have at least one or two nurses that ask ridiculous confidence-sapping questions of the new mother such as "are you sure you have enough milk?" - this type of talk is insensitive and unprofessional - new mothers are typically very emotional and uncertain of their own ability to be good mothers, and many will wilt when questioned or commented upon in this way, relenting to the pressure and accepting the nurse's offer of topping up her nursing with some formula, when in fact this is totally unnecessary and the first step to completely sabotaging mother's milk supply. Free sample tins of formula are also routinely given out to new mothers - it is worthwhile to note that this practice is banned in government hospitals where breastfeeding is recognized as the right way to feed a newborn with formula being reserved only for special medical reasons. Instead of gratefully accepting these free formula samples in the mistaken assumption that formula companies are genuinely altruistic, new mothers would be well advised to consider the fact that once they offer formula to a baby that doesn't really need it they start the process of drying up their own milk supply and will eventually be trapped into becoming paying customers of these same formula companies - a tidy revenue for them indeed!
Many Malaysian babies need treatment for jaundice that occurs within the first week of life. This often involves the need to be admitted to hospital for treatment under UV lights. This is the second critical period that often leads to failure to breastfeed. New mothers should know that even if baby needs to be admitted to hospital for jaundice treatment, they should continue breastfeeding on demand. This means mother must stay in at the hospital with their baby - I have heard of too many women leaving their baby for a night or two - this should not happen at all! The initial period in your baby's life is critical - consider this: a four day old baby who is admitted to hospital for two nights without his mother would have spent one third of his life without her by the time he's ready to go home! You can't spend that long away from your newborn baby and expect there to be no repercussions! Your baby needs you day and night, around the clock. Again, if you are separated from your baby, it means he doesn't learn to suckle correctly and your body doesn't learn to produce enough milk as it lacks the proper stimulation of baby's suckling.
Once home, the fragile budding breastfeeding relationship can still be completely destroyed by certain confinement practices that are harmful. The greatest threat to successful breastfeeding is what I call "the intrusive confinement lady". The worst possible thing a confinement lady can do (and some of them do do this!) is to keep baby away from his mother all night long - this practice is purportedly to allow mother a good night's sleep, supposedly critical to her complete recovery from the ordeal of childbirth. However, for successful breastfeeding, mother needs to feed on demand around the clock. It is the same scenario as already explained above: mother's milk production is not stimulated and eventually dries up. As mentioned in the previous paragraph, your baby needs you day and night, around the clock, especially in the first few months. The confinement diet is another confinement practice that can negatively impact upon a new mother's efforts to breastfeed, specifically three elements of it: herbs, alcohol and lack of drinking water. The confinement diet typically contains lots of Chinese herbs - however, many herbs actually decrease mother's milk production leading to later complaints of insufficient milk for baby - these herbs must be avoided if the new mother aims to continue breastfeeding . The practice of drinking Dom everyday is incompatible with breastfeeding as the alcohol seeps into mother's milk and thus affects baby directly. Finally, nursing mothers are advised to drink enough plain water, approximately 2 large mineral water size bottles or 8 glasses a day - this goes against the traditional confinement practice of completely avoiding plain water, which if followed typically reduces mother's milk supply.
I have pointed out specific preventable yet very commonly occuring events that lead to failure in breastfeeding a newborn. Obviously, new mothers need to take note of these pitfalls ahead of time and decide on a plan of action to avoid or overcome them. Awareness is half the battle - most women who fail at breastfeeding due to the any or all of the reasons mentioned above would most probably not have been prepared when faced with those situations. Before I leave this section, new mothers would be wise to take note that the last preventable reason for giving up on breastfeeding is criticism and lack of support from loved ones - the first month is typically a time when new mothers will be very sensitive and emotional due to hormonal imbalances, and it is very easy to lose confidence or become depressed and just give up when faced with the hurdles at the start of the nursing relationship (most of these have been covered in previous articles in this magazine), but most especially when mothers, mothers-in-law or husbands say to you "why don't you just give up?" or words to that effect. When faced with such discouragement, focus on all the reasons why you should continue with breastfeeding and why it is best for your baby , and keep this knowledge that you are giving your baby the very best start in life through breastfeeding firmly fixed in your mind and heart so that you will have the perseverance to continue - one thing I promise you, it DOES get easier after a month or two!
Issues leading to failure in extended breastfeeding
WHO and UNICEF recommend that infants be exclusively breastfed for the first 6 months of life with complementary foods being introduced after 6 months and breastfeeding continuing up to 2 years of age at least , with the benefits of extended breastfeeding being many and varied , yet hardly any Malaysian mothers achieve this recommendation. The following paragraphs explore some of the reasons for this, in the hope that awareness will lead more nursing mothers to avoid these pitfalls.
Many mothers give up breastfeeding once they return to full-time employment after their maternity leave ends. This need not be the case, though the mother who is determined to continue breastfeeding while holding down a full-time job has to be prepared for a lot of very hard work in the form of regular pumping and storing of breastmilk. Pumping is much harder work than nursing, and mother may not feel the immediate benefit the way she does in the nursing relationship where mother and baby share intimate communion of spirits as they gaze lovingly into one another's eyes - when mother pumps and baby is fed by someone else using a bottle, it may be easy for mother think that it wouldn't really make a difference if that bottle is filled with formula instead of her own milk, and spare her the trouble of 3-hourly pumping sessions even while at work - but it does make a difference. The WHO stipulate that nursing (i.e. direct breastfeeding) is the No.1 choice for infant nutrition, with mother's expressed breastmilk (i.e. pumping) being the No.2 choice when direct nursing is not possible. It is a little known fact that the No.3 choice is to feed baby using another mother's expressed milk, with infant formula only being the No.4 choice when the other options are not possible. So, if you do need to go back to work and are unable to nurse directly during those hours, please be aware that all your hard work of pumping your milk to feed your baby is definitely worth the effort [1,2,3]. However, you also need to be aware that in order to maintain your milk supply, as usual, your milk production needs to be regularly stimulated, or else your body will receive the signal that it is no longer necessary to produce as much milk and your supply will eventually dry up. What this means in practical terms is that you will need to pump at least once or twice while you are at work, depending on how many hours you are away from your baby. Mothers who successfully continue breastfeeding in spite of working full time typically use their morning and afternoon tea breaks as well as lunch breaks to pump. If you skip these, chances are your milk will dry up. And when you are at home, you will need to nurse as usual - be aware that some babies do what is termed "reverse cycling", that is they sleep during most of the day while mother is away and instead stay up all night to enjoy her company, and nurse frequently throughout the night to make up for lost time. This is part of the hard work a working mother will need to put in if she wants to continue to give her baby the best through breastfeeding. To ease mother's fatigue, many opt to cosleep, that is to sleep with baby in their bed, and this is a valid and reasonable way for baby to have his time with mother without unduly disrupting mother's sleep - I will cover the topic of cosleeping, also known as bedsharing, in my article next month.
Another reason for premature ending of breastfeeding is the incorrect introduction of solid foods into baby's diet. The first common mistake Malaysian mothers make is to introduce other foods too early. Current medical advice is exclusive breastfeeding up to the age of 6 months [2,3]. This means baby should receive only breastmilk (or formula) and no other foods or drinks at all before the age of 6 months. This is because baby's digestive system is not yet mature enough to handle any other foods. Yet many introduce cereals and/or rice porridge well before this age. This leads to all sorts of complications, which we do not have the space here to go into, other than the fact that it interferes with long term breastfeeding as baby is filled up with other less nutritious foods. Besides too early introduction of solids, another common mistake is to introduce specific foods before baby is ready for them. Prior to the age of 1 year old, all new foods need to be introduced very carefully, one at a time, according to when baby's digestive system is ready to handle the various food groups. Food charts are available that list when it is safe to introduce what food . Too early introduction of specific foods may lead to negative reactions by baby, such as stomach upset, diarrhea, rashes, constipation, food strikes, and in the worst cases lifelong allergies. These food issues are compounded when baby is fed too much solid food too soon resulting in less intake of breastmilk. In fact, when a mistake has been made and baby has a bad reaction to some food, the best way to get him through the difficult time is to give him as much breastmilk as possible which is easy on his immature digestive system and contains all the nutrients he needs .
A third reason for prematurely ending breastfeeding is incorrect nursing and feeding habits. Up to the age of 1 year old, baby's main food should be breastmilk (or formula when it is unavoidable). Between the ages of 1-2, solid foods gradually replace breastmilk as baby's main diet. [2,3]. However what often happens is once solids are introduced, they very quickly become baby's main food, well before they are supposed to. The reason for this is actually quite simple - some adult (usually one of the grandmothers, but sometimes the parents themselves) decides on how much solids baby is supposed to finish at one meal (typically one bowl of rice porridge) and how often baby is supposed to eat solids (typically three times a day), and proceeds to coax or cajole baby to finish all his food every time. The end result of all this is that baby's tiny tummy is so full that he nurses much less, and mother mistakenly thinks he is outgrowing his need for breastmilk. To avoid this problem is also quite simple. Baby should continue to be nursed on demand throughout the first year - you will find that he settles down into his own typical routine after the initial two months, but that this routine continuously evolves as he grows older. For example, a 3 month old baby may nurse 6-8 times a day, whereas a 1-year old baby may only nurse 4-5 times a day (these are averages only, your baby could be different). Solids should be offered approximately one hour after a nursing session. Baby should never, ever be forced to finish his food as this unnaturally expands his tiny tummy (and is also associated with weight problems in later life!), but should be fed until he himself decides he has had enough. Don't worry if he doesn't eat much, just make sure to provide varied and nutritious food according to what is suitable for his age, and let him eat as he will. Some babies will eat a lot, others very little. Most eat a lot on some days and hardly anything on others. All this is normal and nothing to worry about - as long as baby continues to nurse, all his nutritional needs are being met. With my own baby, she hardly ate much solids up until the age of 9 months, at which time she cut her first teeth. Then she suddenly started eating like a champion, and today at almost 17 months old, she eats whatever I eat, including things that many people have told me their even older children refuse to touch such as raw vegetable salads, fresh fruits, curries and certainly all the staples such as rice, noodles, tosai, naan and pasta. As long as you follow your infant's lead in terms of what he likes to eat and when, keeping in mind medical recommendations , your child will grow up to have healthy eating habits, don't worry!
A fourth challenge to continued breastfeeding is the incorrect interpretation of common nursing phases. As I mentioned above, babies will settle down into their own individual feeding and sleeping routines if things are allowed to progress completely naturally, but these routines themselves do evolve over time. Let us consider three specific disruptions to the regular nursing: nursing strikes, growth spurts and teething. Not all babies go on nursing strikes, but when a baby does and the mother does not realize that there is such a thing as a nursing strike, mother may assume baby suddenly decided to self-wean. In fact, babies younger than 18-24 months do not abruptly self-wean and a sudden rejection of the breast is called a nursing strike . Readers are advised to look up reference  for further details as the causes and remedies for nursing strikes are too many to discuss at length here. Growth spurts are a second disruption to usual routines, with the opposite effect of nursing strikes in that baby seems to want to nurse non-stop and all-night long. Mothers who are not aware of growth spurts may themselves become confused as to why their baby that was previously sleeping for long hours at night suddenly starts waking again and wanting to nurse so frequently and put this down to various other reasons, with the worst reaction being to decide to let baby just cry it out and not allow him to nurse more frequently. In fact, growth spurts last only between 2-3 days to a maximum of about one week, after which time baby settles down into a new and less harrowing (for mother) feeding and sleeping routine again. Growth spurts can be actual rapid physical growth, but similar nursing behaviour occurs in infants about to achieve major milestones such as crawling, walking or talking, where baby needs the extra energy for that extra push in growing his body or brain. . The correct way to respond during a growth spurt is to let baby nurse as often as he needs to - don't worry, this is only a phase and things will settle into a more comfortable routine again very soon - in the meantime, rest assured that you are doing the right thing by supporting his rapid growth! The final disruption to baby's regular nursing and sleeping pattern that we will consider here is teething. A teething baby also often wants to nurse through the night, but more because his gums are uncomfortable as opposed to needing more nutrition. Many other varied and seemingly unrelated symptoms are often caused by teething as well, but in relation to nursing the common ones are increased fussiness, latching on and pulling off of the breast, and biting. This last behaviour can cause even the most dedicated mother to give up on breastfeeding when wounds become too much to bear, but it needn't be this way. Also, before I cause all new mothers to panic in terror at being bitten, let me assure you that not all babies bite and even those that do can be trained not to. Please refer to references  and  for further details as to how to deal with teething in general and biting in particular.
Pseudo-medical issues leading to failure in breastfeeding
I mention this because I have heard of several new mothers whose milk supply dried up when they mistakenly thought they should not breastfeed when they were ill with common illnesses like the flu or a cold. Their decision to stop nursing "for a while" eventually caused them to stop nursing permanently, for the usual reason: when your milk supply is not stimulated your body gets the signal that you no longer need to produce milk and eventually shuts down its production completely. The fact of the matter is that when mother is sick, baby needs her to nurse him more than ever because that is how his immune system is built up - her milk contains antibodies to whatever illness she is facing, and baby will develop immunity through nursing. Mothers who have nursed through illness will testify that they have been surprised that their baby was much stronger and healthier than they themselves were. Often, baby will not catch mother's illness at all, or if they do it will be much milder and of much shorter duration than what mother had to face.
The reverse situation sometimes occurs also - baby is ill and mother decides not to nurse to "let him recover", leading to her milk drying up due to lack of stimulation. Again, to withdraw nursing when baby is ill is the worst possible decision! What better source of nutrition for a sick baby then mother's milk that is perfectly digestible in every way and gentle on baby's entire system? And the antibodies for baby's illness will be present in mother's milk, manufactured by her body in response to his illness - the best medicine possible, far superior to man-made medicines. My own baby has never had to take cough syrup or flu medicines, because she has never been sick with any of these illnesses - she has been exposed to them, and when I noticed flu-like symptoms about to start, it always coincided with her wanting to nurse more frequently which I always allowed her to do - consequently, those early symptoms always vanished within a few short hours, presumably fought off by the antibodies she obtained through nursing. Non breastfed babies simply do not have this extra protection, which explains why they are sick so often.
Genuine medical challenges to successful breastfeeding
I distinguish what I call pseudo medical challenges above from genuine medical challenges discussed in this section because the former appears to be medical reasons for discontinuing breastfeeding but in fact is caused by wrong information while the latter are real reasons that do occur that can cause mothers to give up breastfeeding but can be overcome with determination and right education.
Plugged ducts are uncomfortable and can be painful for mother, but when they escalate into mastitis the pain can become intolerable and side effects include fever and associated symptoms. Plugged ducts are caused by poor or restricted milk flow, typically when baby nurses less frequently for whatever reason, leading to engorgement. Mastitis occurs when plugged ducts become infected. It is critical for nursing to continue during episodes of plugged ducts or mastitis to prevent further complications including breast abscesses. Heat and massage treatment must be accompanied by complete draining of the breast through frequent nursings. Non-aspirin painkillers such as Panadol may be taken to reduce the pain - mastitis is typically treated by your doctor. Please refer to reference  for further details on all aspects of mastitis and plugged ducts.
Thrush is a yeast infection that is often first felt by mother as sharp shooting pain in her breast. It always requires medical treatment for both mother and baby as the fungal infection will affect both. Please refer to reference  for further details.
Premature delivery need not be a barrier to breastfeeding your baby, but sadly in Malaysia support for breastfeeding a premie is often lacking. Mother will need extra help to stimulate her milk production using a double hospital-grade electric breast pump as baby is unlikely to have a strong enough suckle to do so as compared with full-term babies. If the premie has to be on life support and cannot be put to breast at all, mother may have to continue pumping for weeks until he is able to come off life support machinery and suckle on his own. In the meantime, baby may have to be fed via a tube, but the content of these feedings should be mother's milk as it alone is the perfect nutrition for him, with his immature immune system needing all the help it can get from her antibodies. If you are expecting, please look up reference  as nobody ever plans to deliver prematurely, and you don't want to be caught out if you do.
Genuine reasons for failure in breastfeeding and the AP response to this
Sometimes there are genuine medical reasons why breastfeeding fails, such as when mother is undergoing critical treatment for a life threatening illness which medications are incompatible with breastfeeding (for example cancer treatment) or when baby has some critical medical issues that prevent him from suckling. In the latter case, when the issue is baby's and not mother's, the best option would be for mother to pump and feed baby her own milk but from a bottle. In the former case, when mother's milk cannot be available at all, then baby may need to be fed with infant formula from a bottle. Mother's who are forced into this option can still feed their babies in the spirit of AP - this is called "bottle feeding with love". Essentially, all the behaviours of nursing are maintained, with the exception being that baby gets his milk from a bottle instead of from mother's breast. Mother holds baby while feeding him, as opposed to propping up the bottle or getting baby to hold it himself, all the while maintaining eye contact and building that intimate bond of trust and love. This is the AP way to bottle feed. Reference  contains information you need to know about infant formula.