4.2 Common Concerns

I need to sleep and babies sleep better on their tummies--they sleep longer and deeper.

Parents may worry that the baby will not sleep as well on the back. They may also have experienced or heard that a baby sleeps longer when prone and that is a relief to sleep-deprived parents.

Discussion Points to Share with Families

• Some babies have a harder time settling to sleep on their backs when first born and need time to get used to it.
• Breastfeeding is a natural way to help a baby fall asleep on the back.
• Remind them about the “why” for the recommendation. It is true that many babies sleep deeper and longer on their tummies. While that seems like a relief to parents who are very tired, it may well be the reason that it puts babies at greater risk for SIDS. When they are so deeply asleep, they are less reactive to noise, they may experience sudden decreases in heart rate and blood pressure, and they move around less. As they sleep deeply, their bodies may miss the cues that they are rebreathing the air near their faces, and they don’t rouse themselves to move and breath new, fresh air.
• Let parents know that it is important to plan for ways to get help so they can grab some extra sleep in another way, rather than putting the baby at risk. See Module 6. Creating a plan is critical to helping families succeed in implementing safe sleep and breastfeeding.

Believe bringing the baby in bed may help the baby settle better and get to sleep.

This is a very frequently cited reason for bed sharing. It is important, as parents plan for where the baby will sleep, that you help them plan for the possibility that they will take him or her into their bed if they think that is how they will handle baby’s fussiness or if they plan to feed the baby in bed. New mothers and particularly those who are breastfeeding will be sleepy and may fall asleep with the baby in bed no matter what their intention.

Discussion Points to Share with Families

• Fussy babies may settle down more quickly in bed with mother, but studies suggest that they do not necessarily sleep for longer periods of time in that situation. It is good that babies do not sleep for longer periods of time—they need frequent feedings and sleeping deeply and longer is a risk for sleep related death.  Remind them about the information about how babies sleep from Module 1 and let them know that part of their plan for safe sleep will include how to deal with fussy babies and how to get support to catch up on their own sleep in those early months.
• For families that can afford them or have access to them, side cars are now approved sleep surfaces (an attachment to the side of the bed that gives the baby some separate space, but in easy reach of the mother) and may be a solution. The baby and mother are close and mother can reach out and touch the baby and sooth the baby.
• Placing the baby’s sleep surface next to the adult bed makes it easy to check on the baby, reach out and touch the baby and bring the baby into bed for feeding—this can be an alternative to bedsharing.
• Planning for the possibility that a baby will be in the adult bed includes making sure that extra pillows, blankets and other soft or fluffy bedding is removed and that the bed is not placed where the baby can get stuck between the wall and then bed.  Sometimes people try to avoid having the baby in bed by sleeping with the baby in a chair or a couch, but this is actually risker than an adult bed.
• You can remind families about why bed sharing can be a problem:
  • A large proportion of infant deaths in the adult in the bed occur when another person in the bed accidentally rolls over or leans on the baby.
  • Also, many adult beds are made differently than they used to be—they have soft cushioning on top or memory foam. If the baby gets face down on those surfaces, they may not be able to move out of that position to breathe. Even in beds that don’t have that soft surface, adult beds have many pillows and blankets that can be a problem for babies.
  • Beds placed against a wall may have a crack where a baby can get wedged in and unable to breather. Cords or pulls from blinds or drapes that may be over the bed can strangle a baby.
  • Finally having other children sleeping in the bed with the baby can increase the risk of someone rolling over on the baby or covering the baby’s face.
• Note: parents or other adults in the bed smoke are a major risk and they should not share a sleep surface with the baby (exposure to smoke is an overall risk factor for infants and even after the adult is not smoking their clothes or what they are breathing out may expose the baby to tobacco related toxins.).
• Also, if parents are under the influence of drugs, alcohol or take medications that make one sleepy, having the baby sleep in bed is much riskier in terms of potential roll-overs and should be avoided.

If the baby is in the room with us we won’t be able to sleep well and we won’t have any privacy.

This is a concern expressed by parents who also want to deal with sleep deprivation.

Discussion Points to Share with Families

• Having the baby in the same room, but not in the same bed reduces the risk of sleep related deaths. 
• Most babies can sleep through parents’ activities, with a light on to read, etc.—remember babies may sleep in their strollers with lots of traffic noise around them or in the car with the radio playing. They don’t sleep as deeply with others in the room, but that may be what keeps them safer.
• Parents also can get used to the baby noises—for example if one lives near a train track, after a while it is not noticeable. Given some time and less focus on having the baby in the room as a problem, parents can get used to it.
• Having the baby in the same room makes breastfeeding easier and babies who sleep in the same room are more likely to continue with breastfeeding, which protects them from sleep related death and has many, many health and well-being benefits.

Formula fed babies sleep longer and deeper.

Mothers often decide to formula feed because they hear that babies sleep longer and are less hungry.

Discussion Points to Share with Families

• Formula fed babies do sleep longer, however, formula feeding puts the baby at greater risk of SIDS.
• Babies who are breastfed do not sleep as deeply and could more easily arouse themselves if they are not getting enough oxygen. Thus the advice that parents receive to add formula to the baby’s diet to get the baby to sleep longer is counterproductive—sleeping more deeply and longer may increase risk of death.
• Breastfed babies may eat more frequently, because that is how human babies are meant to feed and because breast milk is easily digested. Mothers can get discouraged and may choose to give the baby formula to get more sleep, but that undercuts the breastfeeding process.
• Review information about how babies sleep in Module 2. Of particular interest for this concern is that feeding babies “extra” during the day may result in them feeding less during the night, but they wake up anyway— it is not only hunger that results in those awakenings. That is just how babies sleep.

Firm surface/no pillows seem uncomfortable.

Sometimes families and other caregivers are concerned about having the baby sleep only on a firm surface with no padding and no pillows. They feel that putting a pillow or sheepskin or something else soft under the baby will be more comfortable.

Discussion Points to Share with Families

• What we think of as comfortable may not seem that way to a baby. For most of human history and in many parts of the world, people and their babies did not sleep on soft, cushioned beds. Babies are actually fine on a firm surface. Keeping them safe from having their faces sink into a soft surface and not being able to breathe is important. The same is true of pillows.
• Babies have no experience sleeping on soft surfaces and don’t expect them. They are happy sleeping in many settings.  Think about all the places that babies fall asleep that you wouldn’t find comfortable.

“No blankets”makes no sense.

Families worry that the baby will be too cold without blankets. Sometimes it is   a belief (may be culturally related) that babies need to be kept very warm or need to sweat. Newly immigrated families coming from warm climates may be concerned about how colder temperatures affect babies. In areas where it is extremely cold in the winter and where indoor heating is not adequate, the reality of keeping a baby warm is a challenge.

Discussion Points to Share with Families

• Unless a baby was born prematurely, babies experience the temperature much like adults. If an adult is comfortable with the room temperature, then the baby is probably comfortable. Being overheated is a risk factor for SIDS.
• Blankets present a risk because they can cover the baby’s face and affect breathing, so finding ways, such as dressing a baby in layers or using sleep sacks/blanket sleepers may address the problem when homes are very cold.
• If other relatives are concerned about keeping the baby very warm, part of the family’s plan can include sharing the idea that babies do not need to be warmer, and in fact, being overheated is a risk for SIDS. Keeping blankets off baby’s face and keeping her from overheating is part of good baby care.
• For families who have lived in hot climates, this recommendation may be particularly confusing. It is important to share the idea that blankets and other clothing designed to keep babies warm in the U.S. are made to hold in body heat and the baby cannot kick off blankets or take off clothing as an adult might do when overheated. In addition, young babies’ bodies are not yet efficient in regulating body temperature and this can affect how their heart and other body systems function. Without this context, concerns about overheating may not make sense to families who come from hot climates.
• For families who have beliefs about hot and cold in relation to health it is important to understand those beliefs. Information about how blankets can cover the baby’s face may make more sense to them.

Cannot afford a safe sleep space for the baby.

Families with limited economic means may not be able to purchase a crib or other safe sleep space or may not have space for a separate sleep space. In addition, for families with housing insecurity (living with relatives or friends, moving from place to place, sometimes call “couch surfing”), they may need a portable sleep space that they can easily transfer from place to place, if they are moving from place to place for temporary housing.

Discussion Points to Share with Families

You will need to check resources in your community to provide information for families about what might be available. (Learn more about the importance of knowing community resources as part of the conversations approach in Module 6.) Discussion of this concern relates more to letting families know that are ways to address this issue and that together with them you will figure out a plan.

• Many community groups, health departments, hospitals etc. have giveaway programs that provide a safe sleep surface and that are connected to safe sleep education activities.
• For families with housing insecurity, it is most important to help them connect with resources to address those issues, but reassure them that they can plan for a safe sleeping space for their babies.
•  Even shelters, however, may not provide safe sleep options for families, so again it is important to engage organizations from many sectors in the community to support families’ decisions.

Breastfeeding is more expensive than formula feeding.

Mothers may have heard that it’s expensive to breastfeed, especially if they are going back to work and have to purchase equipment to pump breast milk. Because WIC moms on the non-breastfeeding food package receive infant formula for their baby, some mothers may feel that they’re getting more value compared to breastfeeding WIC moms who receive less, or no, formula.   

Discussion Points to Share with Families

• Breastfeeding can actually save a family up to $1,500 in the baby’s first year that would go to the purchase of formula.
• Breast pumps are not always necessary to breast feed. It depends on the mother’s schedule.
• Private and public insurance may pay for the purchase or rental of breast pumps if they are needed.
• Breastfeeding mothers in WIC receive an enhanced food package and can remain on the program longer than non-breastfeeding mothers. Breastfeeding mothers are also provided with breast pumps and have access to peer counselors, IBCLCs, and designated breastfeeding experts that can help them with their breastfeeding journey.

I can’t breastfeed at work and I don’t think my employer will let me pump milk at work.

Mothers are naturally concerned about continuing breastfeeding when they go back to work. Because in the United States we have such poor policies about maternity leave, sustaining breastfeeding is a challenge for mothers. Mothers in low paying jobs, or those who are worried about issues such as their immigration status, typically have little power in advocating for themselves and are especially vulnerable. There are, however, newer legal supports to help them.

Discussion Points to Share with Families

• Sometimes it is possible to arrange one’s schedule and childcare so that mothers can breastfeed their babies before work, during breaks or lunch etc. Of course as the baby gets beyond the six months of exclusive breastfeeding, the number of times a day the baby needs to be fed will decrease as well.
• If that approach is not possible, then using a breast pump can support ongoing breastfeeding. It takes some preparation to pump milk at work.
• If a person has a job where the mother is paid hourly, and in some cases where she has an overall salary, there is a federal law passed in 2010 that requires employers to provide break time for pumping and a place with privacy to do it (not the bathroom!) They are required to provide this opportunity until the baby is one year old.

The problem is that this law requires that the mother make a complaint to activate any compliance intervention. This is difficult for mothers in low-paying jobs and they may be afraid to advocate for themselves. In Module 6, learn about the importance of helping families find advocates as part of their plans.

• If the job is not covered by the law, the mother can talk to her employer about the fact that breastfeeding is so important that this law exists. In addition, there is important information about helping employers understand how supporting mothers’ breastfeeding is good for their interests. (See Resources in Going Deeper in the left navigation bar.) Ideas to share with employers can include the fact that breastfed babies are usually healthier and thus employees miss less work and that employees who get support for breastfeeding are happier and more productive.

I need to keep the baby in bed with me to keep the baby safe.

Families who live in neighborhoods with high levels of violence see keeping the baby in the adult bed as a potential way to shield them from stray bullets entering the room. Mothers in families where domestic violence is an issue may see keeping the baby near them in bed as a way to protect the baby (and sometimes themselves) from that violence. There are also issues in poor housing with rodents and mothers wanting babies in bed to protect them from rats. These issues are much more immediate in the family’s experience. Plus, SIDS and SUID are not very common and they may not know about anyone who has experienced that type of loss. Unfortunately they may know about children killed by stray bullets or see daily the impact of domestic violence.

Discussion Points to Share with Families

• Acknowledge these concerns and the importance of keeping babies safe in many ways. Discuss if there may be alternatives to having the baby in bed with the parent for protection. As part of a plan, for example, a mother could think about areas of the room least likely to be penetrated by bullets.
• Discuss, if mother plans to bed share, the recommendations for reducing the risks in the adult bed.  See Module 3. or the Handouts from Module 3.
• Also, urge mothers who are concerned about domestic violence to seek help. As part of the plan for that family, provide support in doing so or connect them with those who can.
• Discuss as part of planning, helping families find advocates for safe housing.
• Side cars are now approved sleep surfaces (an attachment to the side of the bed that gives the baby some separate space, but in easy reach of the mother) and may be a solution.  These are not affordable for all families.

I won’t be able to eat my favorite foods any more if I breastfeed.

Mothers have heard that if they are breastfeeding they cannot eat spicy foods, or have to eat certain foods, or drink a lot of milk. Thus, they feel they will be more restricted in their lives if they breastfeed.

Discussion Points to Share with Families

• Women all over the world with very different kinds of diets—spicy, lots of cabbage, etc.—breastfeed successfully, so there are no hard and fast rules.
• Sometimes a particular food a mother eats bothers the baby, but mothers do not usually have to drastically change their diets.
• It is important for mothers to eat a healthy diet for their overall health, but that approach is not required to breastfeed.

I won’t be able to drink alcohol.

Mothers who drink alcohol in moderation and on occasion may worry that they cannot have any alcohol if they are breastfeeding. Mothers may have heard that they cannot drink any alcohol while they are nursing.

Mothers who abuse or drink large amounts of alcohol present a number of challenges and risks in caring for their babies no matter how they choose to feed them. In terms of breastfeeding, alcohol abuse by the mother can result in slow weight gain or failure to thrive in her baby. Babies in adult beds are at particular risk if the adults are intoxicated or taking drugs.  Mothers who regularly drink large amounts of alcohol should not breastfeed, and they put their infants at greater risk if they bed share.  If this situation is the case with a mother you are supporting, then referral to address substance abuse is an important part of the plan for taking the baby home.

Discussion Points to Share with Families

• Occasional, moderate intake of alcohol can be worked around—not breastfeeding until the mother’s body has cleared most of the alcohol from her system, eating at the same time, etc.
•  So having an occasional glass of wine or another alcoholic drink is not a reason to not breastfeed.
• Alcohol does pass into breast milk and can affect the baby by making the baby drowsy, not able to nurse well, and take in less milk. Mothers need to be informed so they can plan for it. Families should seek input from a lactation support provider about this issue. If you do not have this expertise, but would like to know more check in the Resources section of Going Deeper. However, only health care professionals and others with training in lactation support should give specific guidance to mothers.
• Bed sharing should never occur when mother or other adult in the bed has been drinking alcohol. Families should have a separate sleep space for the baby right near their bed.

I will have to stop smoking or else I cannot breastfeed.

Smoking is not good for anyone's health and smoking around the baby leads to increased risk of SIDS and SUID, infections, asthma, and other health problems in infancy and later life It is important not to smoke near the baby, and best if there is no smoking in the house.

Discussion Points to Share with Families

• Being exposed to smoke, even on the clothes of the smoker is a problem for infants and children (as well as adults).
• The risks of bed sharing increase when a mother smokes.
• That said, mothers who smoke less than 20 cigarettes a day can typically breastfeed without problems for the baby, and breastfeeding can be beneficial in providing more protection against infections than formula feeding for infants whose parents smoke.
• Mothers who smoke may note, however, that their milk production is decreased.
• Babies of parents who smoke have been reported to be fussier as well.
• There are important considerations in when and how you smoke if you are breastfeeding A lactation support provider can help mothers plan for how this will affect them.
• An important part of the mother’s plan could include support to quit smoking if she chooses.

If I am breastfeeding, I won’t be able to go anywhere because I can’t leave the baby with anyone—howwill the baby eat?

Mothers are worried that breastfeeding will make the impact of having a new baby on their day-to-day lives even more complicated and difficult. They feel that if they are to sustain breastfeeding, and particularly exclusive breastfeeding, in the first six months that they will be with the baby all the time.

Discussion Points to Share with Families

• It is possible to breastfeed and still can have time away from the baby to socialize, exercise, or even just grocery shop. The time when babies need frequent feedings is relatively short (although it may not seem that way while it is ongoing). In the early weeks it is important for the mother and baby to be together. But mothers can plan outings around feedings.  Also, very young babies are portable and can go with their mothers on outings.
• If it is necessary to be away for a more extended time, mothers can leave pumped milk in a bottle for another caregiver to feed the baby. It may be useful to wait until breastfeeding is established and going well. When the baby is young he/she may take a while to get used to taking a bottle, but being patient will pay off.  Mothers can talk with their breastfeeding support persons about how this can work.

I don’t want to spoil the baby and then have a child who is spoiled and difficult to manage.

Mothers may worry that being “on duty” to breastfeed their babies may lead to the baby being spoiled and clingy. They may worry that the baby is “in charge” and this will set a bad precedent for future child rearing. In addition, having the baby sleep in the same room with the parents and right next to the adult bed raises similar issues. In our broader culture we highly value independence, and keeping the baby so close can be seen as undermining that kind of behavior.

Discussion Points to Share with Families

• Very young babies don’t get spoiled. Being spoiled means understanding the what other people are thinking and doing and planning to manipulate their behavior. Babies don’t have understanding of any of that.  They only are reacting based on their needs.
• Young babies need to be close to those who love them. They are still developing and need to be near a primary caregiver in these early months. This closeness and responding to them is needed for their brains and bodies to develop and help them manage themselves and the world.
• Over time as they develop the capacity to soothe themselves and are more secure about being in the world,   they will be able to become more self-sufficient. In fact, the security that babies get from being close is what allows them to become more independent. Babies who are carried and responded to quickly cry less and are more secure as kindergartners.
• Babies need to feed when they are hungry and not on a schedule. This is not spoiling them. Responding to the baby’s needs is what makes breastfeeding work in the best way—responding to the baby’s hunger assures that there will be enough milk.  So mothers are not “giving in” to the baby in following his or her hunger cues, but working together with the baby to make breastfeeding successful.  

Babies can choke when they sleep on their backs.

There is a common idea that babies might choke when sleeping on their backs because then they spit up, the liquid will go into their airway. This was actually an idea that was promoted by health care providers in the past (some still have this concern and may share that idea with parents.)

There is actually no evidence for this occurring. In fact it is less likely to happen when the baby is on the back.

Discussion Points to Share with Families

Since the time that the recommendations came out to put babies to sleep on their backs, there has been no increase in aspiration (breathing in and choking on liquid spit up). “When the baby is in the back sleep position, the windpipe lies on top of the esophagus, which leads to the stomach. Anything regurgitated or refluxed from the stomach through the esophagus has to work against gravity to enter the trachea and cause choking. When the baby is sleeping on its stomach, such fluids will exit the esophagus and pool at the opening for the trachea, making choking much more likely.” There is a link in the Resources section of Going Deeper in the left navigation bar that provides information and a good picture to show why choking is less likely on the back.

Pacifier use is not supposed to be good for babies’ teeth.

Using a pacifier can be seen as bad for babies. Parents have heard that it will affect how the child’s teeth grow in. Of course for breastfed babies it is important not to introduce a pacifier until breastfeeding is firmly established (baby reliably latches on, baby and mother are doing well with feedings, baby is gaining weight, etc.). It’s also important to make sure that parents learn the baby’s cues for hunger so that a pacifier is not offered instead of the breast, possibly decreasing the milk supply.

Discussion Points to Share with Families

While all types of sucking beyond feeding (important for babies) can affect teeth, the American Academy of Pediatric Dentists notes that breaking the habit of using a pacifier is easier than ending the habit of finger-sucking. As long as the pacifier use does not continue after the child’s permanent teeth have come in (well past infancy) it should not be a problem.

Reminder: Pacifiers should not be offered until breastfeeding is firmly established . A baby should not be forced to accept     a pacifier, and if it falls out while the baby sleeps, the baby should not be wakened to place it back in the baby’s mouth.

Without bumper pads babies can get their heads caught or get injured on the sides of the crib.

Families worry that without bumper pads babies can get their heads or other body parts caught between the slats on the side of a crib or will bump their heads and get injured.

Discussion Points to Share with Families

• If parents and other caregivers are using up-to-date, safety-approved cribs manufactured since 2011 that meet the Consumer Product Safety Commission standards (get link), then the spaces between the slats are too small for a baby to get her head through.
• Dr. Rachel Moon explains the following: young babies (for whom bumpers are designed, given that many carry a warning suggesting that they be removed from the crib once a baby can pull himself to standing) don’t have the muscle strength or coordination to fling themselves across the crib hard enough to really injure themselves.
• Additionally, she adds, while it is possible for a baby to get an arm or a leg stuck between crib slats, it’s virtually impossible to break a limb by doing so—which means that at most, the experience will be uncomfortable and upsetting, but not life-threatening, until a caregiver arrives to help. This is better than a baby getting suffocated by having her face stuck up against bumper pads or being accidentally strangled by the ties that hold them on to the crib.

Cribs are dangerous—they cause “crib death.”

SIDS  or sleep related death were once referred to as “crib death” because babies were found dead in their cribs. While the health and public health world no longer uses this term, it stays in the memory of families.  As a result, there is a concern that somehow cribs caused these deaths. 

Discussion Points to Share with Families

Crib death is an older term for SIDS or sleep related death. It got that name because babies were found dead in their cribs. The crib was not the cause of the death and we now know that being in a crib with a firm mattress and nothing else (blankets, toys, pillows, bumper pads) actually protects babies from these unexpected deaths.

Sleeping on the back causes head deformities—they get flat heads.

Parents may have heard that babies who sleep on their backs get flat spots on their heads from sleeping on their backs.

Discussion Points to Share with Families

• When the idea of keeping babies safe by having them sleep on their backs first came out, it caused some parents to think that babies should never be on their stomachs. As a result, babies did have problems with flat spots on their heads and delayed motor development.
• We now know that “tummy time” is just as important as back sleeping. Tummy time is when the baby is placed on the stomach while the baby is awake and while someone is watching. It is recommended that from the time a baby comes home, it is a good idea to have 2-3 sessions of Tummy Time a day, starting out for 3-5 minutes and getting longer as the baby gets older. This helps with the baby’s development.
• Some other ideas for preventing flat spots on the baby’s head include:
• Holding the baby upright when he or she is not sleeping
• Limiting time in car seats, bouncers, swings or carriers (also important for baby’s development) Changing the direction the baby lies in the crib from week to week.

More information about these recommendations is available in the Resources section of Going Deeper in the left navigation bar.

Bed sharing is necessary for bonding with baby.

Currently there are many who promote bed sharing as an important way to bond with a baby. Parents see that closeness as very important and for parents who are working all day, they feel that having the baby in bed offers time for closeness.

Discussion Points to Share with Families

Bonding with the baby is very important and involves much more than sharing the bed with the baby.  Parents can bond with their baby in important ways that don’t involve bed sharing. Suggestions include:

• Have your baby sleep in your room, right next to you in a separate space where you can still reach out and touch the baby.
• Have supervised skin-to-skin contact after your baby is born and talk to your baby right away. If there are medical reasons this cannot happen, don’t worry. Bonding goes on throughout your baby’s early months. Learn about how to safely continue skin to skin contact at home. More information about safe skin to skin contact is provided in the Resources section of Going Deeper in the left navigation bar.
• Breastfeed your baby—this contact and the opportunity to make eye-contact and talk with your baby are very important. If you are not breastfeeding or if you are pumping your milk when you return to work, whoever is feeding the baby should be face to face with the baby while talking and interacting.
• Keep your baby with you as you go about your activities in a safe baby carrier—this is a great way for fathers or other caregivers to bond with the baby. Make sure you can see the baby’s face, and the baby can breathe well in the carrier. See more information about safe use of baby carriers in the Resources Section in Going Deeper on the left navigation bar.
• Be responsive to your baby’s needs. Very young babies do not get “spoiled”—they are depending on you to figure out why they are crying, since they cannot let you know what they need. Also, studies suggest that before the age of six months (cite) “training” to help your baby settle down to sleep and to sleep longer are probably not effective and not really helpful in bonding with your baby.

Formulais just as healthy as breast milk—they add vitamins and other things to it. (Some parents mayeven think it might be healthier than breast milk).

Of course mothers want the best nutrition for their babies. They may see in commercials that formula adds important vitamins and other nutrients or hear from friends and family that formula babies get better nutrition from formula. Ads also may promote the idea that wealthy and educated women choose formula in the depictions of mothers in their ads, suggesting that it is a better choice.

Discussion Points to Share with Families

Actually the opposite is true. Breast milk is designed by nature to provide babies with all the vitamins and other nutrients they need, and this special mix is designed just for your baby based on who you and the baby are and the environment you are in.  It is personalized nutrition just for your baby. In addition, breast milk has antibodies—these protect babies from getting sick—that cannot be provided by formula. These antibodies are actually specific to the family’s environment so they protect baby from the germs around them. So there is no contest between formula and breast milk on being better nutrition.

Formula is better for babies, because they gain weight faster on formula.

Gaining weight seems better for the baby and formula seems like a modern, responsible way to achieve this.

Discussion Points to Share with Families

• Formula fed babies may weigh more, but this is not necessarily a good thing. A chubby baby is not necessarily a healthier baby. Babies grow at their own rate, and they should be monitored by their health care provider to make sure they are growing well.
• For families who come from areas where food security is a problem or where babies may get diseases that cause them to waste or grow poorly, additional explanation may be needed. Their experience has been that better weight gain as an infant will assure that the child grows up to be strong and healthy.
• It is important to explain that the weight that babies gain from formula is not the kind of weight that shows that they will grow up to be strong and healthy adults. This kind of weight gain can lead to obesity as a child and adult and the many health problems associated with obesity such as diabetes, high blood pressure and heart disease.
• Breastfed babies know how to regulate how much they eat based on how hungry they are, not based on how many ounces of formula given them. This is an important experience may pave the way for normal weight later in life.

Everyone uses formula so it must be better.

Unfortunately in the past two generations or so, breastfeeding has become less common and families may not know anyone who has breastfed. Advertising for formula is throughout the media. These messages also contribute to a sense that everyone uses formula and that it is better for babies.

Discussion Points to Share with Families

According to recent statistics, around 80% of all women in the United States start out breastfeeding. Fewer continue for the 6 months of exclusive breastfeeding and the full year, but even so breastfeeding is not rare. In 2012 almost half of babies were breastfed for 6 months and almost a quarter were breastfed for a year. When you think that just under 4 million babies are born in the U.S. each year, that is a lot of babies being breastfed.

My milk will turn sour or dry up and then there will be nothing for my baby to eat.

Mothers may have heard stories about milk turning sour in their body or milk drying up suddenly.

Discussion Points to Share with Families

• Breast milk cannot curdle inside a woman’s body. It is made fresh for each feeding.
• Sometimes breast milk gets into the baby or mother’s clothing and smells “sour”. It is not sour when the baby is eating it.
• Also milk dries up when the baby stops breastfeeding, so if a mother skips feedings (without pumping) or adds formula, her milk supply will go down. But mothers have control over this process and can always check with a lactation support person with questions.

Cultural and family traditions.

Families often feel that bed sharing is part of their cultural or family tradition. They may note that everyone in their circles bed-shares and no babies have died. In any case, they may feel that this recommendation does not respect their beliefs, values and practices. It is important to ask about their traditions and beliefs before sharing information. While families may not know of an infant who died while beds haring, it is a very common contributor to infant deaths. In some communities, sleep related infant deaths may not be discussed, so it seems there have been none among the community. So discussing the risks of bed sharing and providing them with information about what makes it risky is responsible partnering with the family. At the same time, if families do not feel that their cultural beliefs are being honored, they will not engage with you in further conversation. So just telling them “don’t do it” closes off further dialogue.

Discussion Points to Share with Families

Once you have shared again why this recommendation has been made, then it is important that families have information about reducing the risk of bed sharing for some period of time, even if it is only for few hours, by removing items that create a danger to the baby before-hand. You can discuss with them the aspects of bed sharing that create a risk to the infants so they can address those issues. Also reiterate that sleeping with a baby or feeding a baby when the adult might fall asleep is much more dangerous on a sofa or chair. Also remind them that an adult who smokes or who is impaired by drugs, medications or alcohol should arrange for the baby to sleep on a separate surface. A number of things about adult beds create the risk to infants in bed sharing situations including:

1. Bedding, pillows, etc. covering the infant’s face and blocking breathing.
2. Adult beds placed near a wall or other furniture can create the risk of the infant getting trapped and not able to breathe.
3. Adult beds that are soft—water beds, pillow tops or memory foam— increase the risk that the infant’s face gets stuck in the soft surface and not being able to breath or move to get the oxygen needed.
4. Blankets that cause the infant to get overheated (a risk factor for SIDS)
5. Infants younger than 4 months and premature babies are especially vulnerable.
6. People other than the parents, including other children, because they   may not be attuned to the dangers of rolling over on the infant. Also more people in the bed may increase the risk of crowding leading to accidently laying on the infant or the infant’s face getting blocked.

Breastfeeding is embarrassing, other important people in my life don’t want me to do it, society doesn’t approve or make it easy.

Because breastfeeding has not been common in our society in recent years, it can be seen as strange, or immodest. The sexualization of women’s breasts has become so pervasive that these views impact choices to breastfeed. Mothers worry about being embarrassed if they have to feed the baby in public. Male partners may express feelings about “those breasts are mine” or not wanting others to see the mother’s breasts if she is feeding the baby in public. Because of the societal associations with breasts, there is currently a lot of push-back about mother’s feeding in public places. Women hear about this issue in the news all the time. Because breastfeeding has not been common in the last few generations, women’s mothers also may not support them—women have encountered comments like, “you will look like a cow” or “it seems so hard, why bother?” So mothers need a lot of support to make the decision to breastfeed.

Discussion Points to Share with Families

• In most states, laws allow a mother to breastfeed anywhere mother and baby have a legal right to be. Federal law is also on the side of breastfeeding in public. This does not mean that others will not make it uncomfortable for mothers.
• There are many websites that give tips for breastfeeding in public (Google this and find your favorites to share) and help mothers make a plan so this works for them. Breastfeeding in public does not mean having to show one’s breasts , but that is the mother’s choice. This is an ongoing concern and it will be important to help mothers connect with a lactation support provider and/or a peer breastfeeding support group as part of the plan to deal with this challenge.
• Suggest that the mother share with her partner how important breastfeeding is for the baby’s health and her health. Sometimes we leave the partner out and they don’t understand how important this is. Many partners are very proud that their babies are getting the best nutrition and that they are with a woman who will make this commitment.
• Other family members also may not understand how important breastfeeding is and what is involved. Getting them more information can help them be more supportive.
• One of the key jobs of a mother is to be able to stand up for what is best for her baby, so making the decision to breastfeed and helping others to support that decision is one step in that life-long journey as a mother.

Breastsize affects ability to breastfeed—if your breasts are too big or too small you can’t breastfeed.

Many women have heard that if your breasts are too small you won’t be able to produce enough milk. Conversely, they have heard that if your breasts are too big you won’t be able to manage breastfeeding. In either case, mothers may not even attempt breast feeding, because they don’t want to experience failure and want to make sure their babies will be well fed.

Discussion Points to Share with Families

Size and shape of breasts or nipples don’t have anything to do with how much milk is produced. The tissue that makes breasts large or small is different from the part of the breast that makes the milk and brings it to the nipples for your baby. If a woman has very large breasts, a lactation support person can help her find the best way to hold her baby for feeding so it works. The bottom line is that breast size has nothing to do with how well a woman can make milk for her baby.

Breastfeeding makes your breasts sag.

The many changes women’s bodies go through during and after pregnancy can be unsettling. Given how important body image is our society, concerns about how breastfeeding will affect how a woman’s body will look can be barriers to adopting breastfeeding. A very common belief is that breastfeeding makes your breasts sag.

Discussion Points to Share with Families

It is pregnancy itself that creates changes in a woman’s body, whether she breastfeeds or not. The ligaments of the breast tissue stretch during pregnancy causing breasts to sag. Age, genetics and how many times a woman has been pregnant can make a difference in how much her breasts will sag as she gets older.

Breastfeeding hurts and makes your nipples sore.

Mothers may have heard that breastfeeding hurts or causes sore nipples.

Discussion Points to Share with Families

• If breastfeeding were always painful, it would not be practiced by women all over the world and through the ages. Breastfeeding is not supposed to be painful.
• It may take some time, at first, to get used to the sensations and some initial discomfort. Significant pain means there is a problem that can be fixed.
• Learning about how to care for the nipples and how to help the baby latch on can help prevent problems.
• Just like any new skill, mothers will need to learn how to do it well. They can get help before starting and once they are breastfeeding. Mothers should talk to their breastfeeding support provider on this issue and their plans should include where and how they will get this support.

I take medicines that are not allowed if I am breastfeeding.

Mothers worry about whether the prescription medications they are taking are bad for the baby and if it will prevent them from being able to breastfeed.

Discussion Points to Share with Families

• This is an important issue, and it is good a mother recognizes the potential problems.
• However, not all prescription or over the counter medicines are prohibited for breastfeeding mothers.
• Mothers can talk with their doctors as they plan to breastfeed to learn about which medicines are ok.
• Most of the time the doctor can find something just as effective  that will not harm the baby.
• Remind mothers to also consider supplements, teas and vaccinations and to discuss them with their health care provider to understand how it affects breastfeeding and the baby.