By Lisa Lord, Assistant Editor of Attached Family magazine

When a woman makes the choice to breastfeed, she usually doesn’t anticipate that it won’t work. After all, we are told that almost everyone can breastfeed—and this is true: Lactation is a robust biological process that almost always works.

But though there are only a few medical conditions in which breastfeeding may be limited, there are many medical circumstances that can present lactation and feeding challenges. Mothers who wean early for medical reasons or who are never able to breastfeed at all suffer a loss and may experience a spectrum of emotions that range from disappointment, frustration and anger to guilt, sadness and grief to relief and acceptance.

Editor’s Note: The description of certain medical conditions and breastfeeding recommendations contained in this article are specific to individual cases. It is not advice. Contact your health care provider for medical advice on these or other conditions. Contact an International Board-Certified Lactation Consultant (IBCLC), La Leche League (LLL) Leader or another breastfeeding specialist for more information regarding breastfeeding concerns in your individual case.

A Heartrending Choice

Kim Barbaro of Warminster, Pennsylvania, USA, faced the difficult choice of weaning when she developed a breast abscess that required surgery. Her surgeon explained that the incision would be long and deep, extending into the areola, and would remain open for some time, requiring packing twice a day.

Kim says that while her doctor gave her facts about the surgery, she was also understanding and empathetic: “She absolutely left the decision up to me,” she said. “But she didn’t just talk about the medicine; she talked about the bonding and the quality of time and being a working mom, and that really pulled me to her. It was that level of compassion and understanding that made a gigantic difference.”

“At first I was just confused, definitely torn between two worlds,” Kim added. “I think one of the biggest things for me was that bonding piece [with the baby], because it is so strong, and I didn’t want to be without it. I finally felt like my body was doing what it was supposed to do.”

In the end, Kim decided to wean: “After I started really thinking about it and took the emotional piece out, I knew there was just no way,” she said.

During her recovery, her emotions swung from grief to guilt to resignation, Kim says: “I went through a period of just sadness at that time I was feeding with a bottle. Logically I knew I made the right decision—it was not going to be possible—but emotionally it was another world. I would bounce back and forth, and just when I would get emotional, I would try and tell myself I wasn’t being realistic. You have to convince yourself and get support for that.”

When a mother must wean immediately for medical reasons, support is essential. Mairéad Murphy, IBCLC and La Leche League Leader in Dunboyne, Co. Meath, Ireland, explained: “It’s important that such moms get help on a practical level, because they may need to do some expressing to avoid engorgement and mastitis. But they also need support just to come to terms with the whole thing. It is very much a process of loss and grieving, because this portrait they had of being a mother has changed drastically.”

Kim had planned on a natural labor and birth with midwives, but she ended up with a last-minute Cesarean section. Neither Kim’s birthing experience nor her breastfeeding experience turned out as she wanted.

“I had expectations about how my birth was going to go, and it didn’t go that way,” she said. “And if you go to breastfeeding class, and they tell you all of the benefits and how it is so superior to formula, then you do feel guilty [if you can’t breastfeed]. It’s that mother nurture instinct—you just want to provide.”

When Weaning is the Only Option

It was about the time of her daughter’s first birthday when Wendy Friedlander received the devastating diagnosis that she herself had a rare form of cancer that would require her not only to wean her daughter but to live apart from her for a year while she underwent chemotherapy treatment.

“That was the hardest conversation I ever had in my life,” said Wendy, who lives in New York City, USA. “I wept three boxes of tissues. The doctor literally told me I had to give up a year of my life to save the rest. I had a week before treatment started, before I knew I would have to wean. And it wasn’t just stopping the nursing, it was everything—the babywearing, the breastfeeding, the cosleeping.”

Daytime weaning was easier than expected, as her daughter filled up on hugs and smiles instead of nursing for comfort throughout the day. However, night weaning was more traumatic. In her blog post “Weaning Early,” Wendy wrote: “The night weaning was like ripping off a Band-Aid. Where I was the Band-Aid, and just like that, I was taken away, and it was up to my daughter and her father to get through those first milk-less nights.”

With her large supply of milk, it was imperative for Wendy to continue pumping regularly because a blocked duct could turn into a life-threatening infection. It was a difficult balancing act, removing enough milk to prevent problems while at the same time trying to decrease milk production, all while she was extremely ill from treatments and living apart from her family.

“Everything else seemed so big, weaning was just an aside,” Wendy wrote. “And yet, the pain and heartbreak were tremendous.”

Education and Support are Critical

Apart from genuine contraindications to breastfeeding, there are many medical conditions and circumstances that may affect breastfeeding. With the right diagnosis, information, intervention and support, some breastfeeding may be possible if desired by the mother. Sometimes temporary weaning is needed, or a mother may need to supplement with expressed milk or formula.

Medical professionals may act as barriers to breastfeeding at times: “There are some conditions where breastfeeding is contraindicated, and it’s quite right,” Murphy said. “And there is another group of conditions where mom is told not to breastfeed, and it’s not the truth.”

This is not a condemnation of physicians, most of whom are caring individuals who have the best interests of their patients at heart. However, crushing patient loads, the critical need for good outcomes and simple lack of the most up-to-date information on lactation may lead them to make recommendations that unnecessarily compromise breastfeeding. This underscores a mother’s need for self-education and support.

Mihaela [last name withheld by request] had hepatitis B as a child but had no further problems with the condition for the rest of her teen and adult years. When she was 26 weeks pregnant, a blood test showed what her doctor called “pregnancy hepatitis.” Upon receiving this frightening news, she began having contractions. She spent the next seven weeks in the hospital on bed rest, taking medications for the hepatitis and to prevent further contractions.

“Later on, I learned that even if I had had hepatitis, the chances that the baby would have caught it were minimal,” Mihaela said. She also learned she might not have needed to take the medications she was on.

“I didn’t think to read about it myself. It’s a doctor’s responsibility, and if he doesn’t tell you and can’t self-educate, then you can’t protect yourself,” she added.

Her daughter was born at 34 weeks and was placed in an incubator almost immediately, so Mihaela didn’t have the chance to see her for several hours and didn’t hold her until the next day. Her doctor told Mihaela that she shouldn’t breastfeed because of the medications, and she was given pills to stop lactation.

“I was really sad because I imagined that I would be able to do that, but I didn’t have too much time to think about it [the doctor’s recommendation],” said Mihaela, who had assumed she might be able to begin nursing the baby after a day or two.

She and her daughter spent two weeks in the hospital, in separate rooms, until the baby was gaining weight steadily enough to go home. Looking back, she still feels regret and sadness.

“I feel it would have been much, much easier with breastfeeding,” Mihaela said. “I had moments when I was holding her, and she was close to me…breastfeeding would have complemented that.”

It was especially tough when her daughter would nuzzle her breasts, searching for a way to nurse, Mihaela said: “I would have to take her away from the proximity of the breast. It was really hard.”

Common Complications

If a mother requires medication, she may be told she shouldn’t breastfeed, advice based on resources doctors commonly use, such as the Physician’s Desk Reference or information from the drug manufacturers. According to La Leche League International (LLLI), these resources do not contain complete information about effects on breastfeeding, and very few medications are truly incompatible with breastfeeding. A more useful reference is Dr. Thomas Hale’s Medications and Mother’s Milk or LactMed, the U.S. National Institutes of Health’s Drugs and Lactation Database.

Before Wendy’s biopsy, she asked her anesthesiologist for a list of medications needed for the procedure, “and he didn’t want to give them to me, because he knew I wanted to know for myself when I could nurse my daughter again,” she said. The anesthesiologist told Wendy he would not do the procedure unless she agreed to wait 24 hours to nurse. In the end, Wendy did obtain the list of medicines and learned that she only had to wait eight hours to breastfeed.

There are a number of common conditions that generally should not hinder breastfeeding but often do.

Mastitis is an inflammation in the breast requiring frequent and thorough removal of milk, along with plenty of rest for the mother. “Empty breast, lots of rest,” recommends LLLI. Weaning is not required and may actually worsen the condition. If an antibiotic is needed, there are choices compatible with breastfeeding.

“But it’s still very common that a mother will go to her doctor with symptoms which may or may not be mastitis, and she is often told she needs antibiotics and she must wean in order to take them,” Murphy said. “Sometimes I find moms are told to wean for the duration of antibiotics, but this may be seven to 10 days, and for a very young baby, that may create difficulty getting back to the breast. Or a mother may have trouble keeping her milk supply up. Whereas if she was given the direction of getting into bed, feeding a lot, taking painkillers and so on, it may resolve quickly by itself.”

Many of the common causes of mastitis can be resolved with the help of a lactation consultant, and this is especially important if mastitis occurs more than once.

Jaundice, an excess of bilirubin in the infant’s blood, may cause him to be sleepy and less interested in eating. However, because bilirubin is excreted in stool, it’s critical for babies to continue feeding often to resolve the condition. Mothers may be encouraged to supplement with formula while continuing to breastfeed, which can interfere with milk production and baby’s interest in feeding. Rather than go down the route of giving formula, Murphy says mothers can be shown how to rouse a sleepy newborn, how to get him to take extra feeds and how to supplement if needed.

Once a mother begins supplementing with formula, she might not want to stop, because knowing the exact amount the baby is eating helps moms feel more confident, especially in the face of medical problems. It can be hard for a mother to regain trust in her ability to know that her baby is getting enough milk from breastfeeding.

“Sometimes I think with breastfeeding issues, if you could bottle confidence and give it to mom to drink, then everything would be sorted,” Murphy said. “We are so distanced from the knowledge of normal baby behavior. That lack of recognition causes a lot of problems.”

Deciding to Wean

Sometimes a mother may feel that weaning is the best option for her and her family.

“It all comes down to giving the mom information and letting her make a choice with her specific caregiver,“ Murphy said. “Lots of moms have a different path they are prepared to take with breastfeeding.”

When a mom decides to wean, a good lactation consultant or breastfeeding counselor will respect that and reassure her of the good she has done by breastfeeding up until that point.

“And it truly is good, no matter if she has breastfed for two days,” Murphy said.

Due to the stress and uncertainly caused by breastfeeding difficulties, weaning may bring great relief to an anxious mother. The day I (the author) brought my oldest son home from the hospital was the most stressful day of my life. Breastfeeding was not going well, possibly due to a related medical condition, and I was overwhelmed with worry. After well-intentioned but misguided advice from two counselors didn’t help resolve the issues, and after nine exhausting weeks of nursing, pumping and bottle feeding around the clock, I decided to wean. Though I felt tremendous grief and guilt, I was so relieved be free from the ongoing stress of breastfeeding. It was the right decision at the time—and it also fueled my determination to educate myself and get more support when my second child was born. Mothers who wean may appreciate tips on how to mother the baby in a way as close to breastfeeding as possible.

“Sometimes moms see the end of breastfeeding as the end to all that loveliness, but there are still important ways to enjoy the baby,” Murphy said.

Otherwise known as “bottle nursing,” a term coined by Attachment Parenting International founders Lysa Parker and Barbara Nicholson, authors of Attached at the Heart, mimicking breastfeeding behaviors when bottle-feeding include plenty of eye contact, snuggling at feeding times, skin-to-skin contact and feeding on demand. Mothers may also find bathing together and cosleeping helpful for establishing that initial bond with baby.

Moving On

The process of making peace with weaning is different for every mother, and regret may linger.

“I only listened to one person,” Mihaela said. “I didn’t investigate the problem too much. What I would do is read more, ask more. If I had known more about how the baby would be affected, then probably I would have made other decisions.”

Kim had a strong support network of friends with a variety of breastfeeding experiences, friends who helped her come to terms with her experience.

“You have to say to yourself: This does not make or break your relationship with your child, this is not going to be the one and only bonding thing with your child,” she said.

Now a few years past her successful treatment, Wendy said, “It was a gift in so many ways in the end.”

She says her experience improved her relationships with everyone in her life, and it also left her daughter with a huge network of adults with whom she is very close, though the relatives caring for her daughter during Wendy’s illness didn’t always adhere to the same secure attachment-minded practices that Wendy did.

“In the end, it doesn’t matter because they loved her,” she said. “When it comes to a situation where you are low on reserves and low on support, there is only so much one person can do. Your   children are getting served by love. That is the number-one thing that serves them.”