Tuesday, August 24, 2010

"Los dos" and an awesome new campaign

From the moment my AmeriCorps team started doing breastfeeding education and support in Denver, we came up against "los dos" (literally "the two", better translated as "both"). The majority of our clients, particularly at newborn visits, were Hispanic (largely from Mexico). When we asked them if they were breastfeeding/planning to breastfeed, the answer was almost invariably "los dos" - both breastfeeding, and giving formula by bottle.

I've had a post coming about this for a while - it's a very frustrating thing to deal with and as an inner venting strategy I've composed this post many times in my head.

Why so frustrating? Well, at my current work I see that often "los dos" begins in the hospital. Moms tell me "es que no tengo leche" - "It's that I don't have any milk" - even when I help them hand express abundant colostrum, they don't believe that their colostrum will be enough to sustain baby until their milk comes in. This supplementation often tends to feature HUGE volumes given by bottle (think 1.5 ounces on Day 1, with a baby whose largest feed should probably be 1/3 of an ounce. There is a separate, also long, post about volumes coming - not just about Hispanic moms either.)

Babies get used to the fast flow and firm nipple of the bottle, and they come to expect huge volumes which colostrum cannot provide the first few days. They become fussy at the breast and the mother tells me "es que no quiere el pecho" - "he doesn't want the breast" or "he's refusing it". There seems to be a perception (and believe me, this needs a lot more research) that a large percentage of babies just don't want the breast - with no specific cause or cure - and that if not, you should just give up and bottle feed.

(This, as a side note, is why I think all the people who say nipple confusion is a "myth" are full of it. Over and over again at the newborn clinic in Denver, we'd hear "es que no quiere", slap a nipple shield on, and baby would nurse happily with mom's newly-in milk supply and a nipple that felt more like what they were used to.)

If baby doesn't become nipple preferenced (which some manage to avoid) then continued supplementation often starts to affect milk supply. Mothers tell me they weaned their last babies at one or two months because "no tenía leche" - "I didn't have milk", and "se desesperó" - "he got frustrated" (although used slightly differently it would be mean "to lose hope" which seems so fitting for those babies!)

There seems to be a strong emphasis on babies getting fed a lot, as often as possible, and it's hard to convince/convey to many Hispanic mothers that their babies will get MORE breastmilk if they supplement LESS. Instead, the response to this frustration and dropping milk supply is of course to offer more bottles and fewer breastfeedings. Baby quickly learns where the real supply is coming from and the mother tells me that with her last baby after a few weeks, "no quiso el pecho" - "he refused the breast".

To me all of this is particularly notable as Hispanic moms almost universally tend to want to breastfeed, and when given cooperative babies and milk supplies will generally nurse for a long time - particularly as many stay home to take care of their children. Moms who give up on a nipple preferenced baby will happily nurse the ones who do tolerate "los dos" for a year or two. While many Hispanic moms have yet to make the connection between supplementation and early weaning, I think most of them would prefer to breastfeed longer.

So why is this connection not made? Why is there so much supplementation and so much expectation of "no quiere"? Almost every night at work I dream of rustling up an MPH student to do some focus groups with Hispanic moms on what it means to them to "have milk", for the baby to be satisfied, what they think formula adds to the baby's satisfaction/health, what it means when the baby "doesn't want" the breast, how milk supply is perceived to be driven, etc. etc.

That's still in fantasyland though, so I am so excited that the Massachusetts Breastfeeding Coalition has a new campaign going - the first that I've heard about - targeting "los dos". (Interestingly, they call it "LAS dos" which I've never heard, but maybe it just varies from person to person.)

One poster for the ad campaign has a picture of a baby and a speech bubble saying (in Spanish): "Both (lit. "the two")? Mama, you already have the only two I need! If you give me formula, you won't make enough milk for me." Below it says "Give me only the breast."

Another has the same dialogue with two smiley-faced breasts and a frowny-faced bottle - I love the happy breasts!

And check out the fun story behind the slogan at the Motherwear Breastfeeding Blog!

Will it work? Will moms like it? I hope to hear more about this... and if any MPH/anthropology/sociology/etc. students out there want to get a little qualitative research experience, PLEASE consider this topic!!


The Rabbit in the Moon said...

Have you tried using 3 balls to illustrate the stomach sizes of a day old baby, a 3 day old baby and a 7 day old baby? then explain the connection between colostrum and tiniest amt of colostrum is enough for days 1 - 3? (and that holding is as important as frequency of feeding to the newborn?) Maybe the visual will have a better impact when connected to the verbal.


Once a parent sees this they may be able to understand how ff distorts their baby's stomach.

I hope I am not trying to teach an old dog new tricks here.

Little Miss Me said...

I work in a predominantly Hispanic (think 99.8%) population and I deal with the same frustrating thing day in and day out. I think some of great questions you've asked have varied answers depending on where the mother is from. It has been my observation that a lot of recent immigrants from Central American countries tend to want to do both because they view what the "Americans" are doing as evidence of a higher socioeconomic status. "Oh if the Americans are doing it, then it must be the way to go!"

But mostly, I think that for all Hispanic mothers, a baby "que se queda tranquilito", who sleeps for hours on end, is their definition of a perfect, happy baby who doesn't need anything other than breast.

Preaching "benefits" of breastfeeding to these mothers does not work and that's often the only route a lot of breastfeeding counselors know to take.

I don't know that I'm making much of a difference, but I really focus on normal newborn behavior, on misguided expectations and explain *why* they don't want a baby sleeping hours on end, and on risks of formula feeding.

I think it would be amazing if someone did a study and included the different nationalities of Hispanic women doing both, because personally, I do see a difference in their reasoning even though the end result is the same.

I'm so happy I found this blog! :)

Rebecca said...

@Rabbit: We do have the belly balls and I'll sometimes use them. More often I'll just show by curling my fingers into a circle - "your baby's stomach is just this big". While it can help prevent supplementation just for supplementation's sake, particularly with a fussy baby parents rely on the baby's behavior (fussy="hungry") more than any of my illustrations.

@Little Miss Me: It's true based on your comment & some of the ones on the KellyMom facebook link that has driven so much traffic here (thanks KellyMom!) that I think I did a little too much lumping "Hispanic" women together and didn't disclaim appropriately that they aren't a monolithic group (which is noted in the Motherwear blog.) I probably tend to do this since probably 98% of my Hispanic clients have been from Mexico or Central America, which while not exactly the same are much more similar than, say, Peru and Puerto Rico.

I definitely think the "se queda tranquilito" is HUGE (and is one of the main things I would hope a qualitative study could explore). I talk about this more in that "volumes" post I have coming but I agree that unless baby eats and then sleeps soundly for 3-4 hours mothers are convinced they aren't "satisfied".

Does your teaching on newborn behavior help? How do women respond to this who are on, say, their 4th baby (not unusual!)? (P.S. I'm assuming you work for WIC, is that correct?)

Little Miss Me said...

I do work for WIC. :)

It is so frustrating, especially for THIS population, because you don't have to convince these mothers that breast is best. You don't even have to convince them to breastfeed. They all know this. And I think that is why we're stuck - because we're used to dealing with having to convince moms WHY they should breastfeed. As you said, if they happen to have the rare baby who doesn't exhibit a very strong reaction to the bottle, they will nurse FOR YEARS. I had a mom the other day proudly raise her hand and tell me she nursed her first for 2 years. I stupidly assumed it was without formula and when she clarified, I was momentarily dumbfounded.

So, I had to find a way to get to them and preaching to the choir wasn't working. I talk about SIDS (since the whole putting baby on back to sleep is very new for them as well) and I discuss how one of the common factors in SIDS deaths has been the use of formula. I discuss why babies sleep longer on formula -- not only the difference in gastric emptying time, but also because it's a foreign substance that the baby's body has a hard time figuring out what to do with -- and I compare it to their typical heavy meals after a big festivity - Noche Buena for instance, and how they feel after such a meal...tired, lethargic, unable to move...and I ask them whether they feel healthy...I comment how after such a meal, we sleep very, very deeply, but not very comfortably. That at least gets them thinking.

I am also very, very visual with my props, but I won't give away all my secrets on your blog. ;-) Feel free to email me though as I would love to discuss this further and am happy someone else can understand this very frustrating plight. :)

Little Miss Me said...

Oh, sorry, I didn't address the multiple children question.

Since my population is mostly carribean or south american hispanics, we don't have a lot of moms that have more than 2 or 3 babies and I have A LOT of first time moms. Normally, they are so recently migrated that they DID breastfeed their first child exclusively, because in their country, they did not have a choice. For a lot of those moms, I jokingly tell them that I want to know if they went through the Bermuda Triangle to get here since somehow their breasts stopped working once they touched US soil. :)

For me, personally, one of the MOST frustrating things are the area hospitals that these mothers are birthing in. They KILL any possible chance mother has of getting off to a good start, and the majority of that is out of my control. When I get them prenatally, I can really drive home what the hospital will do and what they can do to counter it.

Most of the time, I don't get them prenatally and then have to deal with the problems they're already having, in large part to that first bottle the hospital gives baby while the mother isn't looking. Some of them don't even think to discuss this with hospital staff because in their country, that would never happen. So then they're confused.

I also run a small breastfeeding support group and I currently have 3 moms who attend who formula fed their first children and are now exclusively breastfeeding, with the exception of the occasional solid which was started after 6 mos, 8 and 9 month old babies. I am so, so proud of them and they both state that having sickly babies due to formula and more support and knowledge has been the key to their success.

How do you handle the moms that have more than 1? Do you find that they also supplemented with their first if their first wasn't born here?

Rebecca said...

I would love to talk to you more over e-mail! I couldn't find your address on your blogger profile/blogs so feel free to e-mail me (publichealthdoula@gmail.com)

Rebecca said...

Even at a "good" hospital I know we're not doing everything we could to support breastfeeding, I can only imagine what it's like elsewhere (well, I have seen it to some extent).

The moms who have more than 1 are hard. If she did "los dos" for the last 3 who is this crazy young gringa telling her that she shouldn't? I try to emphasize giving more breastmilk and less formula. Usually I don't have time to investigate who was born where, but it's an interesting question, maybe I'll try to start asking it when I get the chance...

Rebecca said...

And your support group sounds awesome!! I would LOVE to be part of something like that...

Emily said...

Ah... I've been looking for a direction to go for my master's thesis topic ;)

Your posts are always so educational and pertinent to my new field of study. Thanks :)