No Shame, No Blame: The Art of Talking With Breastfeeding Mothers

There is a subtle but important difference between “Could you get her to latch?” and “Was she able to latch?” The first question assesses the mother’s ability. The second assesses the infant. Even if the problem is a maternal one, the focus can still be on helping the infant do better. Examples of mother-oriented and infant-oriented language are presented in Table 1.

A critique of the mother’s positioning (which she may not know how to change) or a negative assessment of her anatomy (which she cannot change) can erode the mother’s confidence in her own abilities. Lack of maternal confidence contributes to early cessation of breastfeeding, so our words should be identifying strengths, offering solutions, and celebrating successes rather than pointing out deficiencies or failures.¹ 

For decades, sufficiency of early feedings has been assessed by calculating the percentage of weight lost day by day. In the first few days, mothers are often barraged with negative messages about the infant’s weight just when they feel most vulnerable about milk supply. “Down,” “losing,” “lost,” and “lower” are discouraging to hear.

The Newborn Weight Loss tool (newbornweight.org) is invaluable in this regard because it provides peer-group–based comparisons.^2,3  The infant who has lost 8% on day 3 may well be above the 50th percentile if born by cesarean delivery and exclusively breastfeeding. For the mother, “better than average” is a completely different message than “lost 8%.”

Peer comparisons are also useful when the infant’s weight is concerning. References to normative data help parents understand the situation. “Not where we hoped it would be” or “more than most babies her age” provide information and a context for the conversation and plan that follows.

In our bottle-familiar culture, new mothers often think the infant should be sucking on the nipple. Phrases like “latching onto the nipple” reinforce this notion. A clear description of what the infant should do is better. “Her lower lip and tongue should be below the nipple so that her tongue is massaging the breast, where the milk is, instead of rubbing on the nipple.”

The normal transition between the first day (“sleepy baby”) and the second and third day (“fussy baby”) is often unexpected and hard. Retrospective reassurance may seem dismissive to the mother who believes a low milk supply is causing her infant to cry. It is easier to trust words from someone who has predicted the change. “Your baby might be fussy and want to eat very frequently tonight, but we can put a ‘do not disturb’ sign on your door so you can rest this afternoon.”

Future predictions also give parents a context for changing recommendations. “Excessive sleepiness is common on the first day, but if your baby is sleeping through feedings after that, it could be a sign of illness or insufficient milk intake.”

The regular nursery is a place where reassurance flows fast and furiously. Many things about newborns, normal to us, are unusual and concerning for new mothers. “Red, blotchy rash all over his body”: normal. “Her eyes cross”: normal. “He’s losing weight”: normal.

Reassurance is fine, but the boundaries of our reassurance need to be clear. We empower mothers by letting them know where those boundaries are. “A few drops of colostrum per feeding is enough for today, but when she is 4 days old, she’ll need about an ounce each time.”

The ability to feed the infant adequately is inextricably connected to the mother’s sense of her role. Articulate mothers sometimes express feeling they are “failing at being a mother” when the breastfeeding is a struggle. And those words from women who have only been mothers for a few days!

There is a fine line between providing education and reassurance about milk supply and discouraging a mother from trusting her instincts. We need to do the first without doing the second. Words like “It’s important for him to get enough, but a teaspoon per feeding is sufficient for today” are informative and helpful. Words like “Just keep trying” in response to the mother’s discouragement over her empty-feeling breasts and crying infant are not.

“Enough” milk is not much at first. Most mothers have no sense of breast fullness, let-down, or emptying for 2 to 3 days, so almost all mothers are worried their infants are not getting enough milk.⁴ 

However, we need to stop saying “It’s enough” just because the feeding frequency meets our expectations. The truth is no one knows exactly how much colostrum is moving from the mother’s breast into the infant during a feeding. Fortunately, most infants do get enough. But some do not. For those few, the words “It’s enough” will be ringing in their ears decades later and leave them feeling lied to.

Instead, focus on observable facts: latch, urine and stool output, weight, physical appearance, etc. Providing the rationale for our reassurance forces us to consider all the available information and empowers mothers to do the same.

Speaking negatively about past supplementation (or the lack of it) is a shame-inducing exercise. Depending on word choice, mothers can feel scolded (or worse!) by those who are trying to support breastfeeding. This is both damaging and unhelpful. Accept the present reality, whatever it is, and go from there.

Years ago, I thought breastfeeding was a nursing issue. After all, why should nursing the infant not be a nursing issue? I have learned a lot since then. Physicians are also an important source of support.¹ 

Let me illustrate: I recently visited a mom who had delivered her first infant 16 hours before. The feedings had not been going well. She mentioned at least twice that she had asked for formula and none had been provided. She was clearly irritated. My 25-years-ago self would probably have taken action to fulfill her request.

My current approach is different. I asked about the feeding experience. I examined the infant, who was healthy and happy to suck on my finger. I offered to watch him eat. She brought him close; he fell asleep. To entice him to latch, I asked the mom for permission to touch her breast and let her know I was going to press a bit to get some colostrum out. The drop emerged. The infant did nothing. At that point, I moved the infant to the crib and showed the mother how she could get the milk out herself. Drops of colostrum started rolling down her breast. The mother’s look of surprise and pleasure was priceless. “Look how much you have!” I said. “For today, whenever he won’t cooperate with latching, how about if you get the milk out and feed it to him?” The whole process took <10 minutes.

There was no more talk of formula, not that day or the day after. It was not because I talked her out of it, but because she could sense within herself that she was already enough.

And that, in my view, is what our breastfeeding support words should be all about.

Jane Morton, MD, Julie Lipps Kim, MD, and Jessie Allen, MD, provided valuable feedback on early versions of this article.