Weaning the Breastfed Baby

by Star Rodriguez, IBCLC for The Leaky Boob
this post made possible by the generous support of Fairhaven Health.

breastfeeding latch

In my practice, I do prenatal consults.  During these, almost 100% of the time, people ask me, “So, how long am I supposed to do this, anyway?”  I typically tell pregnant moms and their families that the American Academy of Pediatrics recommends that you exclusively nurse for 6 months, continuing until at least a year once complimentary foods are introduced.  The World Health Organization recommends nursing until two years of age.  However, I always caution my families that breastfeeding is a very personal thing between a mother and baby dyad and that people typically have an idea of when they are done nursing.  This may vary from what you thought it would be while pregnant, or what it was during other breastfeeding relationships.

There are two different types of weaning.  Baby initiated weaning and mother initiated weaning.  Baby initiated weaning is probably the easiest way to do it.  The baby generally gradually starts nursing less and less until baby just eventually stops.  It’s easy for baby and easy for mom.  Well, mostly.  With either baby initiated weaning or mother initiated, there can be some sad feelings when the breastfeeding relationship ends.  Check out the post on weaning ceremonies to find ways to celebrate the nursing relationship.

A word of caution: some babies exhibit behaviors that we call nursing strikes.  Nursing strikes are not cues to wean.  They are when a baby who is normally fine with breastfeeding, or happy at the breast, will suddenly refuse it and become fussy, often in the first year.  This is typically not a baby signaling intent to wean.  It is usually linked to something like illness, teething, an increase in social behavior, or something like that.  True baby initiated weaning is not usually accompanied by an unhappy baby.

With mother initiated weaning the mother decides, for some reason, to cease breastfeeding.  This is a little harder on most babies, because typical breastfed babies like to nurse.  It is not, however, as hard as some people make it out to be.  I have had patients tell me that they cannot possibly nurse their babies because it will be a very difficult endeavor to wean them.  Trust that if you decide you are done breastfeeding, at any age you can stop, and you will probably not have to spend millions in therapy because of it.

I rarely recommend weaning cold turkey (where you just stop weaning, with no gradual step down.)    There are a few reasons why this is a bad plan in most circumstances.  First, babies don’t often take well to this.  If you suddenly stop breastfeeding and give babies just bottles, most of them will be a little confused and a lot upset.  Secondly, it’s not great for Mom, either.  Moms that wean suddenly often experience engorgement (again!) and can experience plugged ducts and infections.  It’s just not a lot of fun.

There are, however, some medical reasons that you may need to wean cold turkey.  First, make sure that this isn’t something that will only interrupt breastfeeding short term.  If it is, you may be able to pump and dump during that time and resume nursing after if you would like.  If it is a long term thing, though, try not to feel guilty or upset.  Many of these reasons for needing to wean are serious emergencies to one’s mental or physical health, and in those circumstances, do not worry about the short term effects to your baby.  No, it is not ideal.  But your baby will not benefit as much from gradual diminishment of breastfeeding as they will from a healthy parent.  If you are in pain from sudden weaning, you can express a little milk when you are uncomfortable until your milk begins to dry up.  You may be able to use other things to help your milk dry up faster, but if you have weaned for a medical reason, you should always check with your medical provider first.

In lieu of needing to wean immediately, most in the breastfeeding community favor the gradual approach.  In this, you replace one feeding, beginning with the least favorite, with something else.  For a baby that is nursing as a form of primary nourishment, such as those that are under a year, you will have to replace that feeding with an equal source of nourishment.  For most babies, this will be formula or expressed breastmilk.  Hopefully, your baby will accept another method of feeding already, but, if not, be sure to keep an open mind.  You may offer the new type of feeding; someone else may offer it; and you can think of various different ways to give your baby nourishment (bottle, cup, sippy cup, syringe, etc., depending on age.)  If you have an older child who is receiving her primary nourishment from other foods, like most nursing toddlers, you can offer things like water (or another liquid) from a cup, a snack, or some kind of redirection.  You can also explain to your child – “We aren’t going to nurse right now, so we’re going to do (whatever) instead.”  Older children may not ask for it, and, if that happens, it is probably better to just not say anything at all.

After you have taken out that first, least important feeding, wait a few days or weeks (base this on the comfort of you and your baby – if your breasts are feeling overfull, or your child is not handling the transition well, you should wait a little longer until you adjust) and remove the next feeding.  That should be the new least important one.  (When I discuss the least important feedings, I mean the one the baby is the least attached to.  For example, often, the most important feeding is right before bedtime, and the least is during the day at some point.  Your mileage may vary, though.)  Again, wait until your breasts and baby have adjusted, and then repeat as needed.  You may find that partial weaning, where you remove some feedings while still allowing others, may be an option, too, if you are weaning for non-medical reasons.

During the time that you are weaning your baby, remember to be gentle on them – and you!  As I stated before, weaning can be an emotional experience for everyone, and the emotions may vary, a lot.  Some people feel happy and disappointed all at once.  Whatever you feel is ok.  Give your child lots of cuddles and kisses during this time.  You will both benefit from this and it will ease the transition.  When it is time to wean, whenever that is for you and your child, many moms discover that the relationship they have with their child changes some and while it is normal to miss what you had, new ways of bonding and sharing time together will emerge for you both to enjoy.

 _________________________

How old was your baby when you weaned?  How did you feel?

_________________________

 

 

 

 

 

Share

Medications and Breastfeeding

by Star Rodriguez, IBCLC 

This post made possible in part by the generous support of Rumina Nursingwear.

 

It can be really confusing taking medications or having procedures done while you are breastfeeding.  Most of the time, if you look at the package insert or online, most medications simply say that you should ask your doctor or not take them while breastfeeding.  Then you might hear something completely different from friends, or relatives, pharmacist, or from your doctor.  So what do you do?

Well, luckily, there are a bunch of fantastic resources for breastfeeding moms.

First, I want to tell you that research on breastfeeding and medications has come a long way in the past few years.  So your doctor, nurse practitioner, or pharmacist may have outdated information.  I am not trying to say that you shouldn’t respect your provider or that they don’t know what they are talking about.  That’s absolutely not true.  However, the amount of breastfeeding patients or customers that they see is probably relatively small, so their continuing education is often focused elsewhere.  If you are wondering if information that you were given is correct, you have every right to research that yourself and then bring that information back to your provider so you can make an informed decision together.

Medications moving into milk depend on several things, and, sometimes, even if they do, they do not enter the bloodstream of the baby.  Describing the hows and whys of that could literally take me twenty (probably boring to most people) pages, so I’ll cut to the more important things: how to tell what your medication is ranked, taking you baby’s age into account, resources for information, and supply issues from medications.

Drugs are typically ranked in L categories.  These categories are, as per Dr. Thomas Hale:

L1 – Safest.  These drugs either don’t reach the baby at all or have been proven to be safe in large studies.

L2 – Safer.  These drugs have either been studied to a lesser degree with little to no side effects on the baby, or, after taking the evidence into account, the likelihood of this drug being problematic to your baby is pretty remote.

L3 – Moderate.  This category is where most drugs start.  L3 drugs either have no studies done, or studies have been done showing minimal problems to the infant if the mom is taking it.  This is the category where it’s really a risk/benefit situation.  What are the risks of the drug in your breast milk versus the risks of feeding formula?

L4 – Possibly Hazardous.  We know that this drug can have adverse effects on the baby.  However, there might be some situations where use of this drug is justified.  For instance, if someone is in a life-threatening situation.  For the most part, though, we want to avoid these medications.

L5 – Contradicted.  You can’t use these while breastfeeding.  We know that they have significant, documented, negative impacts on babies.  If you have to take a L5, you cannot breastfeed while it is present in your milk.

 

Sometimes the classification of medications can vary based on where you are in your breastfeeding relationship.  In the first week of breastfeeding, due to the difference in colostrum versus mature milk, it can be a little easier for medications to pass into milk in greater quantity.  If you can avoid a drug during that time, you should.  However, maintenance medications, pain relievers used for surgical deliveries or painful vaginal deliveries don’t need to be avoided.

In the later stages of breastfeeding, after solids are introduced, most babies begin to take in a little less milk – and in the toddler stage, that often lowers again.  So if you are nursing in a later stage, some medications that were once not ok can be acceptable again.

So now that you have a basic idea about how drugs are coded, where do you find this all out? 

LactMed is a website that has a bunch of information about drugs and breastfeeding.  It doesn’t have the L classification, but it does talk about the drug’s potential effect on lactation.  For instance, if you look up Sudafed, it talks about how it might lower production of milk.  LactMed also has a free Android and iPhone app.  I haven’t tried out the app itself yet, though, so I’m not certain what, if any, differences there are.

Medications and Mother’s Milk  is a book that is updated every 2 years.  Many libraries have it, as do most pharmacies, hospitals, WIC clinics, and doctor’s offices.  It is written by Dr. Thomas Hale, and has a wealth of information on drugs and breastmilk, including the L classification.

Infant Risk Center is a website that has a bunch of information regarding pregnancy, breastfeeding, and the risks to infants of various things.  It is directly connected to Dr. Hale, who is the foremost authority on breastfeeding and medications.  The site itself can sometimes be a little difficult to find the specific information that you’d like.  However, Dr. Hale also has an app (it is a paid app, but it has a HUGE amount of information, so if you’re a provider, or you regularly work with breastfeeding moms, I can’t endorse it enough.  For the mom who is occasionally taking medication, it’s probably not necessary, though.)  The Infant Risk Center is also staffed Monday – Friday 8am – 5pm CST to answer questions about breastfeeding (and pregnancy) and medications, and the people working it are knowledgeable, helpful, and generally wonderful.

When looking at medications, it is important to consider whether they can impact supply.  For instance, as I mentioned, Sudafed can be problematic in that area.  Generally, if a medication is meant to dry something up, or impacts your hormones (like birth control), you should exercise caution in using it.  Before anyone worries, you can still take birth control.  You may want to use an IUD, the mini pill, or Depo Provera if you are not planning to use barrier methods.  With Depo or the Mirena IUD, I usually tell moms to ask to be on a month of the mini-pill first; some moms just have sensitivities to hormones, and those sensitivities can impact supply.  Depo can’t be removed once injected, and Mirena is expensive to place and uncomfortable to remove, so it is good to have an idea if you will react that way.  Also, hormonal birth control should not be started until at least 6 weeks postpartum after milk supply is established.

I hope this information helps you work with your health care provider to determine the best choice for you when you need medication.

___________________________________________

Did you have to take medications while breastfeeding?  Was it easy for you to find good information on them?

___________________________________________

 Star Rodriguiz, IBCLC, began her career helping women breastfeed as a breastfeeding peer counselor for a WIC in the Midwest.  Today she is a hospital based lactation consultant who also does private practice work through Lactastic Services.  She recently moved to the northern US with her two daughters and they are learning to cope with early October snowfalls (her Facebook page is here, go “like” for great support). 
Share

The Basics of Tongue and Lip Tie: Related Issues, Assessment and Treatment

By Melissa Cole, IBCLC, RLC and Bobby Ghaheri, MD., Portland OR.

“Tongue-tie” has become quite a buzz word in some circles and is still quite unknown in others.  Tongue-tie, professionally known as ankyloglossia, is a congenital condition in which the lingual (tongue) or labial (lip) frenulum is too tight, causing restrictions in movement that can cause significant difficulty with breastfeeding and, in some instances, other health concerns like dental, digestive and speech issues.  Mothers of infants dealing with feeding challenges are often desperate to find solutions; as awareness increases about tongue and lip tie, some mothers wonder if this is something their baby may be coping with.

Parents often want to know what some typical signs of tongue/lip tie are.  Each mother/baby dyad is very unique and therefore tongue/lip tie issues can present differently for everyone.  Some common symptoms that may point to the infant being tongue/ lip tied include: poor latch/inability to latch, sliding off the nipple, fatigue during feeds ,sleepy feeds, poor weight gain, clicking during a feed , maternal nipple pain/damage (can feel like the infant is compressing, chewing, gumming, pinching, scraping the nipple, etc), increased maternal nipple/breast infections, compromised maternal milk supply, dribbling milk at the breast/bottle, digestive issues (increased gassiness, reflux, etc due to extra are being swallowed and poor control of the milk during a swallow), and various other feeding related challenges. Some mothers and babies may cope with some of these issues, all of these issues or even none of these issues when a tongue/lip tie presents. We must keep in mind having a frenulum is not the problem; compromised tongue mobility and functionality that cause problems for the mother and/or baby are the problem!

Mothers are tech-savvy and often turn to the computer first to research what might be causing their feeding concerns. When moms go online, they will most likely encounter some discussion about how tongue and/or lip ties can cause feeding issues.  If parents suspect a tongue/ lip tie then families will often want to see a provider in-person to have their baby evaluated and treated.  Sometimes families are lucky enough to have a local provider well-versed in evaluating and treating oral restrictions like tongue and lip tie.  However, many mothers may not have access to this expertise in their local communities. If you suspect that your infant may have a tongue or lip tie and you’re not able to find a provider in your community to evaluate and treat this condition, consider connecting with a local international board certified lactation consultant (IBCLC) that should be able to help connect you with additional resources. Another resource is the website for the International Affiliation of Tongue-Tie Professionals (IATP) (please note that the website is just about to be launched and may or may not be live at present, do check back if needed).

Tongue Tie

Tongue tie, released

Tongue and lip ties come in various shapes and sizes and can present uniquely in every baby.  Many providers have only been trained to look for very prominent, classic tongue ties that often create a heart-shaped tongue.  However, tongue ties can be sneaky and restrictions that are more posterior (toward the base of the tongue) cannot be easily visualized.  Proper assessment and evaluation are key when identifying these types of ties because they can easily be missed at first glance.  Not all providers know how to properly assess for all types of tongue and lip restrictions.  While there are various assessment tools and tongue-tied classification scales that have been published, there is still no universally accepted standard of assessment and care when it comes to tongue and lip tie.  This fluctuation in assessment and treatment standards can be extremely frustrating for parents trying to seek evaluation and care for their potentially tongue and lip tied infant.  If you are unsure of whether or not your provider is adept at assessing or treating various types of tongue and lip tie you may want to ask your provider the following questions:

  • How do you assess for tongue/lip tie?
  • How often do you treat tongue/lip tie in your practice?
  • Do you treat posterior tongue ties?
  • How do you perform the procedure?
  • What type of follow-up care to recommend after the procedure?

Providers that routinely assess and treat babies for tongue and lip tie should be able to easily answer these questions and provide parents with enough information so that they can make an informed decision.  Providers that may not be the best to assess or treat your baby include ones that rarely assess or treat for this condition, tell parents that the tongue tie will stretch or that it’s not a big deal, tell parents that they have never heard of it posterior tongue tie, or tell parents that this must be done under general anesthesia.  Parents should always feel empowered to seek additional opinions and advocate for the needs of their child if they are struggling to find a provider that understands and treat oral restrictions.

Lip Tie

Lip tie, released

If a tongue or lip tie is present and parents wish to seek treatment, what can parents expect?  Various types of providers treat tongue and lip tie including: ear nose throat doctors (ENTs), pediatric dentist, oral surgeons, pediatricians, naturopathic physicians, and others qualified to do minor surgery.  In most all cases, releasing the frenulum for infants is an in-office procedure, with no sedation needed.  In some rare cases, or in cases with older children, sometimes light sedation is used if the parents or provider feel that the older child would be too stressed while alert, but in infants this is usually not necessary at all.  Some providers release the frenulum with sterile scissors, others use laser technology. The availability and types of providers in any given community will vary as will the course of treatment.  In general, this is what we tell parents coming to our practice to expect (please note that other providers may perform the treatment slightly different ways):

What to expect when your baby needs a frenotomy/frenectomy:

In general, the procedure is very well tolerated by babies.  We take every measure to ensure that pain is minimized.

1)    For a typical frenotomy (an incision of the frenulum), a topical numbing gel is applied once or twice and occasionally, if a frenectomy (frenulum tissue is removed) is needed, a small amount of local anesthetic is injected.  Often, ice chips are applied directly to the area before (and sometimes after), as this helps numb the area.

2)    Crying and fussiness are quite common, and most children lose only a small amount of blood.  They will frequently drool afterwards until the numbing medicine wears off.

3)    Pressure and ice are held to help minimize any bleeding, and the child will be returned back to you, where you have the option of immediate breastfeeding, bottle feeding or soothing depending on your preference.

4)    Tylenol may be used afterwards but is often not even needed.

5)    You may notice some dark brown stools or spit-ups afterwards as some blood may get swallowed after the procedure.

There is very little risk involved with the frenotomy/frenectomy procedure.  The biggest risk of the procedure is the potential for re-attachment to occur.  In order to prevent this from happening, we work with the patient’s in our practice to keep the newly-released area open and healing well by encouraging specific mouth-work after the procedure.  We encourage gently massaging/stretching the incised area, targeted oral motor work to help the tongue and mouth learning patterns, supportive bodywork, and other complementary healing modalities.  By incorporating this type of gentle aftercare, we do see a reduction in reattachment and better progress overall.

Over the decades, it is no doubt that many breastfeeding relationships have probably suffered greatly due to undiagnosed tongue or lip restrictions.  While more providers and parents are becoming educated about ties, we must be mindful not to think that every feeding challenge is created by a tongue or lip tie or that releasing restrictions will immediately improve the feeding situation.  Sometimes there is immediate improvement after the procedure and sometimes it is a gradual process as the tongue is supported in moving in new ways.  Feeding challenges can be complex and involve layers of issues.  In addition, tongue/lip tie can create other issues that may need to be proactively addressed.  Infants and mothers may cope with muscular tightness, nipple damage/pain, milk supply issues, infant weight gain concerns, etc. that need further support before and after a tongue/lip tie is evaluated and treated.  Working with a qualified, experienced board certified lactation consultant or other care providers that are familiar with oral restrictions is highly suggested.  Coping with feeding challenges in a tongue/lip tied infant can be an emotional and physical roller coaster for families.  It is our goal in writing this article that all mothers and babies receive the care they need and that awareness in regards to tongue/lip tie issues will continue to increase worldwide.

For additional resources on tongue and lip tie, please visit Luna Lactation’s website resource page and scroll down to the tongue tie section.

 

Biographies

Melissa Cole, IBCLC, RLC is a board certified lactation consultant in private practice.  Melissa has been passionate about providing comprehensive, holistic lactation care and education to parents and healthcare professionals for over a decade.  She is an Adjunct Professor at Birthingway College of Midwifery in Portland, OR where she teaches advanced clinical lactation skills.  She is active with several lactation and healthcare professional associations including La Leche League and the International Affiliation of Tongue-Tie Professionals.  To contact Melissa feel free to email her at [email protected] or follow her on Facebook and Twitter @LunaLactation.  You can read more from Melissa at lunalactation.com.

 

 

Bobby Ghaheri, MD is a board certified ear, nose and throat specialist with The Oregon Clinic in Portland, OR. His interest in treating children with tongue and lip-tie stems from his ardent support of breastfeeding and was furthered by his personal experiences, as his youngest child benefited from treatment for it. He enjoys working with children and has an interest in traditional and non-traditional approaches to pediatric pain control. To communicate with him, feel free to email him at [email protected] or follow him on Twitter at @DrGhaheri.  You can read more from Dr. Ghaheri at The Wrinkle Whisperer.
References

Coryllos, E., Genna, C. W., & Salloum, A. C. (2004). Congenital tongue-tie and its impact on breastfeeding.  Retrieved from http://www2.aap.org/breastfeeding/files/pdf/bbm-8-27%20Newsletter.pdf.

Ghaheri, B., & Cole, M. (2012). General Information about Frenulum Procedures for the Infant (pp. 2).

Hazelbaker, A. K. (2010). Tongue-Tie: Morphogenesis, Impact, Assessment and Treatment: Aidan and Eva Press.

Kotlow, L. (2011). Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. European archives of paediatric dentistry : official journal of the European Academy of Paediatric Dentistry, 12(2), 106-112.

Share

In Search of the perfect latch

Sugarbaby 1 week old. Photo by Kelli Elizabeth Photography

“I’m really scared of breastfeeding.”  Pregnant with her first my friend subconsciously rubbed her 34 week belly as I made dinner and we chatted.  Puzzled, I asked her why.  She said she googled and learned that it can be so painful, particularly if they don’t have a good latch.

“How do you get a good latch?” she asked me.  She went on to explain that she had read different blogs and forums about how hard it was to get a good latch, women with bleeding nipples, and babies not gaining weight.  She wondered what was the secret to a good latch and what if it didn’t happen for her.  It’s true that these issues do happen and probably far too often but here she was, weeks away from having her little baby, scheduled to take a breastfeeding class in the next couple of weeks, and worried that she was facing a world of pain if she couldn’t get this elusive latch and not find the secret for it ever to happen.

Earlier that same day I had coffee with a good friend, an IBCLC at a local hospital.  The topic of the elusive perfect latch came up and she surprised me by telling me that she thinks we make too big deal about the latch.

“If mom isn’t in pain and baby has plenty of soiled and wet diapers, why do we need to mess with anything?  Sure, if there’s a problem such as pain or a dehydrated baby then we need to fix what we can but so what if that bottom lip is curled in if it’s not bothering anything.”

In other words, if it’s comfortable and it’s working, it’s a good latch.  There is a wide range of normal.

I love this woman, she often says exactly what I’m thinking.

In general, if everything is working right, babies are ready to breastfeed and mom’s breasts are ready to feed.  It just works and we really don’t need to mess with it, it doesn’t have to be this complicated endeavor.  Maybe it will be difficult but we don’t have to expect trouble.  More often than not moms need support simply because breastfeeding isn’t so common in our society and women don’t see breastfeeding as a part of normal life making the learning curve steeper than it would be if seeing breastfeeding was commonplace.  There would be less stressing about the perfect latch if more women saw what it looks like when a baby is at the breast as they go about daily life.  Their moms, sisters, aunts, friends, coworkers, or even strangers breastfeeding would have already demonstrated a baby feeding well.  The wide range of normal would be seen and experienced.  Today a woman may never see another woman breastfeeding until she’s feeding her own baby for the first time.  Seeking out support she may look online or join a breastfeeding support group, seeing breastfeeding dyads in a very specific setting that she had to find.  If she is experiencing difficulty with pain or ineffective milk transfer for her baby, because she hasn’t been exposed to breastfeeding pairs, she may not even realize that the way her baby is latched could be what’s causing the problem or that it may even be a fairly simple fix.  When there are issues such as poor weight gain for baby or bleeding nipples the first thing to consider is a poor latch.  After I shared a few pictures of Sugarbaby’s latch on Facebook, there were several comments and I received several emails from moms stating that they never knew saw what a latch looked like and had endured pain in breastfeeding because they didn’t realize something was wrong.  Side note: if you are ever experiencing pain with breastfeeding that is more than a brief moment of discomfort or lasts beyond initial latch please seek out help, pain is usually an indication of a problem than can be corrected.  This doesn’t mean you’re doing something wrong, it just means you probably need help.

 I talked with my friend Star Rodriguez, IBCLC of Lactastic Services and WIC peer counselor for the following lists.

When do you need to consider latch issues and improving your nursling’s latch?

  •  When breastfeeding is painful beyond the initial latching.
  • When there is tissue damage to your nipples.
  • When there are weight gain issues for the baby.

What latch pointers can moms try?

  • Mom is in a comfortable position and has brought the baby to her level to her instead of leaning down to the baby.
  • Baby has wide open mouth.
  • Baby’s body is facing yours and baby’s arms are not pushing away at you.
  • It is best to let the breast fall naturally if possible.
  • If large breasted or when milk first comes in, it may be helpful to hold your breast with your hand.
  • Aim baby’s nose toward the nipple; if necessary to encourage a wider mouth, tickle the very top of the baby’s upper lip with your nipple.
  • Latch should be asymmetrical. Chin will touch the breast, nose will be unobstructed. You do not need to push your breast away from your baby’s nose in a good latch.
  • You will hear or see baby swallowing – short sucks/swallows at first, longer ones as milk starts to let down.
  • If using a nipple shield, ensure that the nipple and surrounding tissue is being pulled into the shield.

What can a mom do to try to improve a painful or ineffective latch?

  • If baby isn’t opening mouth wide enough, attempt to show baby by opening your own mouth wide.  Many babies will subconsciously mimic this.
  • Make a “breastwich” with your hand in the shape of a C behind the areola to help baby get a bigger mouthful.
  • Get baby as naked as possible for skin-to-skin or lightly dressed.
  • Hold baby securely, a snug, close hold will help.
  • Pull baby in quickly when mouth is open wide.
  • It is common to experience some discomfort at latch in the first few weeks of breastfeeding.  It should go away as the feeding continues.  If it does not end after around 30 seconds, you may need to remove the baby from the breast and reposition the baby.  Break the suction by placing your little finger into the corner of the baby’s mouth and trying to latch again.  Some lactation consultants can show you ways to fix a latch without taking the baby off the breast, but those are easier to learn from being shown rather than told.  You may need to put the baby in a different nursing hold or position.

When should a lactation consultant be called?

  • Repositioning doesn’t work
  • If there is sudden soreness after there has been painless nursing
  • If you feel stabbing or burning pain in breasts or at latch
  • If you have cracked or bleeding nipples
  • If your latch is not painful but your baby is not having a good amount of wet and dirty diapers

Check out these other resources on latch:

11 Common Pitfalls When Latching a Newborn

 

Latching and positioning resources

Latching: Thoughts on Pressing Baby’s chin down

 The Mother-Baby Dance

 

Coming soon a photo gallery of latched on babies and their mother’s commentaries on their latch experience illustrating the wide range of normal and potentially problematic latches. 

 

Share

The WIC Breastfeeding Peer Counselor program- why you should care

It’s déjà vu for me today, Leakies.

Last year, right around this time, I wrote an article for this very site about how a representative was proposing that we removing funding from the WIC breastfeeding peer counselor program, The High Life of a WIC BReastfeeding Counselor.  That was struck down, and quickly, but sadly enough, threats to the program loom again.

In case you don’t know what the breastfeeding peer counselor program is, it’s an awesome program at WIC where breastfeeding or former breastfeeding moms are hired and thoroughly trained to provide breastfeeding advice and support.  In fact, our training is so awesome and the program is so respected that the organization that tests people to become registered lactation consultants, IBLCE, allows it as one of the few ways to gather the hands on hours required to take the examination.  The program helps both new moms and moms-to-be with a variety of breastfeeding issues.  We teach classes, we do one-on-one counseling, and we assess moms and babies who are having issues.  We can catch issues early and fix them or refer to someone who can.  We run support groups and work with businesses and hospitals to make the community a more supportive place for women who do choose to breastfeed.  We run warmlines.  Some of us do home or hospital visitations.  Many of us are IBCLCs.  What we do, in a private practice setting, would cost you a LOT of money.  Yet, for the women who qualify for WIC, these services are totally free.

And although we are all breastfeeding advocates, we’re not going to force you to breastfeed or look down on you if you don’t.  We will encourage you and help you, but we will not force our goals or ideals on you, and we will not look down on you if you don’t breastfeed for as long as we would or in the way that we would or even at all.  There’s something pretty amazing, though, about seeing a new mom who really, really wants to breastfeed, so incredibly tired and sore and unhappy and on the verge of giving up light up when she is given the tools needed to make things work for her.  And these tools are sadly unavailable in many other places.  Many doctors aren’t all the breastfeeding savvy.  Hospitals that have lactation consultants often only have them there part time, or they are too overbooked to give moms the time that they need.  La Leche League meetings can be at times that a new mom can’t manage – especially if she’s also working.

Money for breastfeeding support within WIC was already cut once this year.  This is pretty sad, given that the Surgeon General’s call to action to support breastfeeding was issued just a year ago.  We know the numerous benefits of breastfeeding, and we know that while so many moms want to breastfeed, a significant amount simply aren’t meeting their goals.  Mother to mother support is proven to be a huge help.  And when that support is trained and qualified to bust myths and give realistic advice while not being judgmental, that’s even better.

A House subcommittee yesterday passed a bill for funding for WIC that has no money earmarked for peer counselors. That, combined with the lowered budget overall, means that a lot of ladies will be losing their jobs and a lot of moms will be losing what might be the only education and support they have for breastfeeding.  While my office is amazing and everyone is supportive of breastfeeding and decently educated, and while I believe that WIC has taken steps to ensure that is the norm, there are many agencies that only maintain a counselor because that money is earmarked.  The peer counselor in those offices may be the only person there well versed in breastfeeding and holding the solutions to common issues.  If we take her away, there will be a lot of moms that switch to formula – not because they want to, but because they feel like they have no choice in the matter.

So why should you care?

Well, if you believe that women should be supported in their breastfeeding endeavors, you want breastfeeding peer counselors to keep their funding.  If you are someone who doesn’t care about breastfeeding but wants government spending to decrease, then you want breastfeeding peer counselors to keep their jobs.  You see, we help women to be healthier and have healthier babies, which translates into less money spent on state insurance and less spent on purchasing formula.  If you’re a business owner or manager, you want us to keep our funding, because by helping moms to keep breastfeeding and continuing to confer that specifically tailored immune protection, your employees’ babies are at their optimal health, and your employees will be at work more often, increasing productivity.

I urge you to sign this petition and consider letting your elected officials know that cutting funding to this program is ridiculous and short-sighted.  It may save some money short term, but it will have significant consequences long term.

 

 

 Star Rodriguiz, IBCLC, is a breastfeeding peer counselor for a WIC in the Midwest and has just started her private practice as an IBCLC (her Facebook page is here, go “like” for great support).  She also sits on the  breastfeeding task force in her town, is helping her  community’s Early Head Start redefine  their breastfeeding support, and is the  driving force behind a local breastfeeding campaign.  In  the remainder of her free  time, she chases around her nursling and preschooler.

 

Share

Bottle Feeding Breastfed Babies

 

by Tanya Lieberman, IBCLC, with Amy Peterson, IBCLC

We’re very pleased to share an interview about bottles and breastfed babies today. We asked Amy Peterson, IBCLC, co-author of Balancing Breast and Bottle: Reaching your Breastfeeding Goals, to answer our questions.

For those of you who combine bottles with breastfeeding – whether you’re pumping at work, supplementing, or use a bottle for occasional separations – bottle and nipple selection can be confusing. For those of you whose babies refuse bottles, it can be very frustrating!

We hope that the information she shares below is helpful. Amy offers more information on bottlefeeding breastfed babies on her website.

Many bottles are advertised as “easing the transition from breast to bottle” and back again. What do you think of these claims? Are they independently verified?

These claims are very misleading. Just as every mother’s breast has a unique shape and flow, every baby has a unique suck/swallow cycle. What works well for one baby might be terrible for another. Parents need to observe their own baby sucking on a bottle nipple and analyze if the latch and swallow look similar to that on the breast. In our book, we use a tool called the SIMPLE Method that guides parents step-by-step on how to choose a bottle nipple for their own baby’s unique latch.

We are not aware if such advertising claims have been verified. However, we do know that this type of marketing is in violation of the International Code of Breastmilk Substitutes. This international health policy document, adopted by many countries excluding the U.S., is designed to protect families from underhanded marketing ploys such as words or pictures idealizing artificial feeding. Comparing a bottle to breastfeeding—even if it contains breastmilk—is idealizing that brand.

In our professional experience of helping babies combine breast and bottle-feeding, we have found that the nipples which claim to be best for breastfed babies are often the worst choice. The bottle nipples that are best for breastfed babies have a gradual transition from tip to base.

You and your co-author tested 37 bottles. What were the features you were comparing, and what did you learn about the range of bottles that you’d most want parents of breastfed babies to know?

We tested two different aspects of bottle nipples. First, we measured dripping by looking at the number of drips and the size of each drip. Then we hooked up bottles to a hospital grade breast pump to determine how fast bottles flow. After performing these tests, we compared the results to see if bottle dripping and flow rate were related.

The results were surprising. First of all, about half of the nipples, regardless of a non-“no drip” label stopped dripping within five seconds of tipping them upside-down. That was important for us because many bottle companies claim their nipples are “no drip,” implying that bottles that don’t drip are a better choice. To rule out the importance of dripping, we did further testing.

Second, we measured the size of the drip for those bottles that did drip. The most important thing we found was dripping does not equal a higher amount of liquid. Bottles that appeared to drip a lot often had less volume. Frequently it is assumed that a fast dripping bottle has a large amount in the drip. We discovered that a bottle may drip frequently, but with a low output. So, it is impossible to judge the size of the drip with the naked eye. Stated another way, the number of drips doesn’t mean more liquid is coming out.

As for flow, the term “slow” is not standard. To determine flow, we hooked up bottles to a hospital grade breast pump and measured the amount of liquid collected after 20 cycles. We found there was a wide range of “slow.” For example, the fastest nipple was eleven times faster than the slowest nipple. Following testing, we ranked nipples from slowest to fastest in Appendix C of Balancing Breast and Bottle. This is important because if a nipple flows too quickly, a baby’s suck will become disorganized. Likewise, a nipple might be too slow for some babies. A parent needs to watch their baby’s response to bottle-feeding rather than relying on package labeling. If a parent thinks the bottle is flowing too fast, try a different nipple in the package, and/or try a different brand.

The most fascinating results came from comparing the data of these two tests (drip and flow). Dripping is different than flow; they are not related. Most breastfeeding books suggest turning a bottle over to see how fast it drips in an effort to select a bottle with a slow flow. This suggestion is not accurate. We tested a nipple that dripped an average of 56 times when tipped over, but had a slow flow. Then, we looked at a no-drip nipple and much to our surprise, found it flowed 10.6 times faster. Big difference! Dripping is not related to flow.

Parents are often advised to begin breastfed babies on “slow flow nipples,” but even nipples advertised as “slow flow” can seem very fast. Are there any that are as slow as you think is appropriate?

As mentioned earlier, the term “slow” is not standardized. Nonetheless, it is important to begin with a slow nipple. If a nipple flows too quickly, a baby’s suck will become disorganized. For breastfeeding babies, it is best to choose a flow that mimics mom’s flow. For this reason, it is hard to say one or two brands are “best” since flow varies from mother to mother. Likewise, a nipple might be too slow for some babies. This is why we ranked the bottles and listed them in our book.

It is also important to remember that flow is only one aspect of choosing a bottle. If the baby’s mouth placement is wrong, regardless of the flow, baby will bring bad habits to the breast and still be in danger of early weaning.

For parents who are struggling to get their breastfed babies to take bottles, and who are exploring different bottles, what should they be looking for?

Moms need to consider the nipple shape and their baby’s mouth placement on the nipple. Ideally, the nipple chosen will gradually flare from the nipple length to the nipple base. This shape allows the tip of the nipple to reach far back into the baby’s mouth as the breast does, and then helps the baby to feed with the mouth open. Quite often a “narrow neck” nipple has a shape that reaches far into the baby’s mouth and allows for gradual widening of the baby’s lips.

A shape that often does not work well is a wide neck nipple where the nipple length meets the nipple base at a right angle. This nipple shape promotes what we call “straw” sucking, where the baby’s mouth closes around the length of the nipple and doesn’t open for the base. When babies “straw” suck on a bottle nipple, we often see gaps in the corners of the baby’s mouth which leads to leaking milk, gulping air, etc. This is quite different than breastfeeding.

One bottle feeding method is called “paced feeding.” Can you describe it and explain why it might be helpful to a breastfed baby? What are some signs that a baby is becoming overwhelmed while bottle feeding?

Paced feeding refers to helping a baby eat more slowly from the bottle. Pacing became popular in 2002, before flow had been studied. The idea behind pacing is that by helping the baby rest briefly during bottle-feeding, moms can more closely mimic how the baby naturally feeds at the breast. When a baby breastfeeds, the mother has several let-downs during the feeding. Between let-downs, the baby’s sucking slows and baby can rest briefly. If a baby is feeding from a fast flow “slow flow” nipple, the suck/swallow will be disorganized. Pacing helps the baby have rest periods while bottle feeding that naturally occur at the breast. Now that we know flow can be controlled by choosing an appropriate nipple, we have another technique in our bag of tricks to help babies be more coordinated when feeding from a bottle.

It is important to note that most babies can pace themselves once they master bottle-feeding with the right nipple. How do you pace? First, listen for swallowing while the baby is breastfeeding, noting when the baby naturally pauses and rests. Then apply the same rhythm to bottle-feeding. Also of importance is positioning. With bottle-feeding, support the baby in a more upright position because the flow of some bottles increases when the baby is laying back to feed (another element we tested).

Do all breastfed babies require pacing? No, in fact, imposing pacing can disrupt the natural feeding rhythm of a baby and cause harm when over used. Babies who are “good” feeders, meaning they have a normal, rhythmic suck/burst cycle, do not need pacing. It has been our experience that once a baby has mastered bottle feeding, it is no longer necessary for the parent to impose pacing.

Some signs of a poor bottle-feed include gulping, catch-up breaths, fast feeds, leaking milk from the sides of the mouth or down the chin, baby who has a furrowed brow looking very concerned, and a baby who pulls away from the bottle. For these babies, nipple shape and flow need to be double checked, and this becomes a good time to use pacing. Pacing also is an excellent technique for NICU and other high risk babies that are having feeding difficulties.

Lastly, we would like every caregiver who uses a bottle to know that dripping bottles given before a baby begins sucking usually cause the baby to pull back or flat out refuse the bottle. Caregivers need to be sure the nipple is not dripping when the bottle is offered to the baby. Allow the bottle to stop dripping or keep the milk tipped down in the bottom of the bottle. This topic is further explored on our website.

 

 

 Tanya Lieberman is a lactation consultant (IBCLC) who has helped nursing moms  in hospital and pediatric settings.  She writes and produces podcasts for several  breastfeeding websites, including  Motherwear,  Motherlove Herbal Company, and  the Best for Babes Foundation.  Tanya recently authored Spanish for Breastfeeding Support, a guide to help lactation consultants support Spanish-  speaking moms.  Prior to becoming a lactation consultant she was senior  education policy staff to the California legislature and Governor, and served as a  UN civilian peacekeeper.  Tanya is passionate about supporting nursing moms, and especially to eliminating the barriers so many moms face in meeting their breastfeeding goals. She lives in Massachusetts with her husband, her 8 year old son and her 1 year old daughter.

 

Share

Nipple confusion, bottles, and alternative feeding options

On January 17, 2012 in the United States, Medela, best known for their pumps, launched their latest “feeding innovation”, the Calma.  The Calma is a bottle that seeks to eliminate nipple confusion and flow preference by making a bottle fed baby work for its milk, similar to how your little one must compress and suck at your breast to get milk out.  According to Medela, this “supports an easy transition from the breast to the teat and back.”

As a registered International board certified lactation consultant, I am very skeptical of these claims.

I have often heard that nipple confusion is a myth, foisted on mothers to keep them stuck to their brand new babies, to keep them from leaving the house, to subjugate us all.  This is simply not true.  Nipple confusion happens.  I have seen numerous cases of it in my practice.  Babies become nipple confused for three reasons – flow preference, difference in movements, and difference in feel.  Medela has the right idea on part of the equation.  Babies that are given a lot of bottles in the early period can decide that it’s not that fun to work a breast when this plastic thingy is way easier.  Most bottles, even the slowest flowing, flow faster than milk from a breast.  However, your baby also moves their mouth differently to get the milk from a bottle than from a breast.  The jaw and tongue movements are not even close to the same, and trying to transfer the movements from one to another can frustrate and upset your baby.  After all, if your baby is new, this whole eating thing is new, too.  Why complicate it?  There’s a bonus too: a baby nursing at the breast will develop their mouth in a way that will help with prettier smiles and better speech, too!

The third part of the equation is the different feel.  If you are giving your baby a softer breast and a harder silicone, they may very well like the way that a bottle feels more – especially since that silicone is, again, delivering milk faster and the mouth movements are different.   Medela hasn’t really done anything to cure that.  I’ve seen and felt the Calma, and, I assure you, it will not be mistaken for breast tissue anytime soon.

The easiest way to prevent nipple confusion is by waiting to introduce a bottle until four to six weeks (three to four at the earliest) and to simply offer the breast more than the bottle.  Some families have other situations, though, that don’t make the whole four to six week thing possible.  So what is a modern mom to do?  For many of us, it is not feasible to never give milk from anywhere but the breast.  We have work, and school, and other children, and obligations, and, man, sometimes Mommy just needs a day (or an hour or two) off.   But babies still have to eat during that time!  And what if your baby has issues with latching at the breast, or you are inducing a supply, or you need to do some supplementing?

Luckily, being a modern mom means that we have some awesome options available to us.  There is spoon feeding, where you can hand express colostrum or milk directly into a spoon and give it to your baby.  This works best in the beginning, when your baby isn’t taking in much milk yet – it would be a fairly long process for a family feeding an older infant.  To spoon feed, you simply use a clean spoon, hold the baby in an upright position (like sitting) and put the spoon at the lower lip, giving small amounts and letting the baby go at their own pace.  A spoonful can be considered a full feeding if you are dealing with a newborn.

Cup feeding is another option.  Cups are widely available, cheap, and easy to use.  Your infant won’t take the cup from your hands and drink like a big kid, of course, but will instead lap at the milk kind of like a baby animal might.  There are special cups sold for cup feeding, but it might be easier and cheaper to just use a shot glass.  With cup feeding, like spoon feeding, you’ll hold the baby supported and upright.  You’ll put the cup to the lips and tilt slightly so that the baby can easily lap at the milk (not so it’s pouring into his or her mouth.)  Allow the baby to eat at his or her own pace.  It may take a while, but that is ok!  Babies shouldn’t be gulping down their feeds – when they do, they often overeat, which can hurt their tummies and set a bad precedence of wanting more than they need.

You can also use what’s called a supplemental nursing system, or SNS.  SNSs are generally a bottle type thing hooked to a long tube.  You put the milk in the bottle part, and then you can do one of two things with the tube.  First, you can use it on the breast, either by sticking it in a nipple shield (which you should only use if followed by a lactation consultant for sizing and to negate any potential complications that might arise) or by taping the end near the nipple so that the baby gets an extra boost of liquid while nursing.  This can be really helpful if you’re relactating or increasing a milk supply, if your baby needs to be supplemented but is nursing well, or if you have a preemie or baby with suck issues that maybe doesn’t milk the breast as effectively as they should be.  You can also use a SNS to finger feed your baby.  With that, you attach the tube to your finger, and the baby sucks the finger to get the milk.  A lactation consultant can even help you use this method to train or retrain your baby to suck properly.  SNS systems can be hard to clean, so please carefully read the instructions and check with a health care provider for any extra precautions you should take if you have a preemie or immune compromised baby.

If you have an older baby (4 months or so) that’s just now getting around to taking milk in another way, you can try forgoing bottles altogether and working on cup training or using sippy cups.  Sometimes the difference is interesting enough for an older baby who has rejected bottles.  As with any of the other methods, the goal is to allow your baby to learn and go at their own pace.  Be prepared for this to be a messier endeavor with an older baby who is starting to show some independence.  You will probably have to help them to hold and tilt the cup – they may not be content with the idea of you holding it all yourself, and you may have some spills in the process.

But what if none of these methods work for you?  Maybe your care provider is balking, or you are annoyed and uncomfortable with one or all of the methods, and you really, really just want to use a bottle.  In that case, instead of purchasing the reportedly $15 a piece Calma, I would try Fleur at Nurtured Child’s method of baby-led bottlefeeding.  In fact, any time you are bottlefeeding, you should use this method.  It is the ideal way to feed a baby from a bottle and encourage any care-takers that will be feeding your baby with a bottle to utilize this method as well.  In choosing a bottle, there is no really good evidence that I have seen showing that a certain bottle or nipple is better than another for breastfeeding.  There are a lot of nipples that are supposed to be similar to your breast in look and feel, but in my time in the bottle aisle, I never saw any that made me go, “That looks EXACTLY like my boob.  That one, right there, with the wide base and medium sized nipple!!”  My kids never really liked the wide bottomed nipples, although they are often touted as being awesome for breastfeeding babies.  When it all boils down to it, most of that is hype.  When selecting a bottle, select the one you think might work that is in your budget.

If you are giving milk due to a breastfeeding problem, be sure to discuss methods and supplements with a medical professional with good lactation training.  Ask a lot of questions.  If supplements are ordered, get a LOT of information on them.  Why do you need to supplement?  How long does your medical professional want you to supplement?  How much should you supplement?  How often should you supplement?  Can you use your own expressed breast milk?  What is the plan of action for weaning from supplementing?  If your baby isn’t nursing well at the breast, you will likely need to do some pumping along with the supplementing to keep your supply healthy while you work through the problem.  Find out how often you need to pump and how you should store your breastmilk – especially if your baby is hospitalized and you are transporting it.

There are other feeding options for more serious problems, such as cleft lip/palate as well. That type of situation needs to be followed very closely by a lactation professional and physician to ensure that the baby’s unique situation is being addressed.

If you are going to be separated from your baby for another reason – work, school, or just going out – remember to think of your magic number.  This is the number of times your baby breastfeeds in a normal day (and, yes, that can vary.  Just take an average.)  You want to be sure that you are replicating that amount of times by a combination of pumping and nursing.  This will help to keep your milk supply plentiful.

In the end, there is no product on the market that can magically be just like your breast and provide your baby the exact same experience.  Luckily, there are many options for your baby and your family that will help you to achieve your breastfeeding goals.

 

 
 Star Rodriguiz, IBCLC, is a breastfeeding peer counselor for a WIC in the Midwest and has just started her private practice as an IBCLC (her Facebook page is here, go “like” for great support).  She also sits on the  breastfeeding task force in her town, is helping her  community’s Early Head Start redefine  their breastfeeding support, and is the  driving force behind a local breastfeeding campaign.  In  the remainder of her free  time, she chases around her nursling and preschooler.
Share

Once Upon a Time- A tale of a journey towards being an IBCLC

by Star Rodriguez

Once upon a time, I was a brand new mom-to-be and I was going to breastfeed.  I was determined and informed and ready to go.
And then I had my baby and everything went crazy.  If there was a breastfeeding complication, I felt like I was hit with it.  I had horrifically bad advice and support.  We made it 14 months, but it was a serious struggle.  In that struggle, there were a few beacons of awesomeness – my pediatrician, who was not well informed on breastfeeding but was totally willing to admit that and send me elsewhere for realistic help , and a couple of IBCLCs.  There were also a few terrible people, including nurses and an IBCLC.
At one point during the whole ordeal, I remember thinking, “You know, I’m going to look into being an IBCLC, because women need help, and if this is any indication, they’re not getting it.”  At the time, the requirements dictated what I thought was an absurd amount of contact and lactation specific education hours for me to be able to do it, so I put the thought from my mind and moved on.
Fast forward three years, and I have baby #2.  The incorrect information and bad support in the hospital persisted.  Luckily, I was no longer a novice – but even as an educated mom who had breastfed before, I found myself getting a little nervous about the scary picture the nurses painted as my daughter – delivered at 42 weeks by c-section following hours of IV fluids – lost “an excessive amount of weight in the first 24 hours.”  A simple Google search found research papers identifying IV fluids as a determining factor in inflated birth weights – however, none of the nurses at the hospital where my daughter was delivered professed to know anything about that.
It was then that my interest in promoting correct, evidence based lactation support came back to the forefront.  I was lucky to obtain a job as a Breastfeeding Peer Counselor at WIC, and I decided to use those counseling hours to take the IBCLC exam.  You know, eventually.  Like 2012.  I would take some college classes to meet the 2012 requirements for the exam (here are the official requirements, criticized by many for being slanted towards those with a medical background – ie, nurses and doctors.)
In August, a series of random events occurred that left me with ability – and a need – to spend more time at work.  What was very part time increased and I began to wonder – what if I sat the IBCLC this year?  After doing all sorts of math, I realized that getting all of my contact hours (I needed a thousand) was possible, if only just.  I talked to my boss and family, and decided to go for it.  Thus began a crash course in everything lactation related.  I felt, for quite some time, like my life revolved around working and studying.  I read everything from textbooks on lactation to research papers to statistics texts to Medications and Mother’s Milk.  I joined study groups online and made flash cards and attempted to memorize the difference in looks between a herpes blister on the breast versus poison ivy versus eczema.  There is a ridiculous amount of knowledge on breastfeeding out there, and some of it is quite different based on where you are globally.  Since the IBCLC is an international exam (so your certification can be used anywhere in the world) there were certain things that I had to condition myself to think of in a global context instead of in an American one.  I also had to fit in 45 hours of lactation specific education.
I sat the IBCLC exam on July 25th 2011.  It was probably the most daunting test of my entire life, and I quite honestly am still not certain how I did on it.   Most people who take the IBCLC exam pass; however, the exam grading process is very complex.  It’s graded on the “Nedelsky” method, which is incredibly complex.  Not only that, but during the exam, all candidates are given sheets allowing them to dispute questions that they consider unfair or incorrect.  These sheets are all taken into account and certain questions can be thrown out based on them.  Candidates do not know, going into the exam, what percentage will be passing; it varies by year and is not known until the day the results are released.  All in all, it takes the International Board of Lactation Consultant Examiners about 3 months to get the results out.  For me, this will be Friday October 28th.  Candidates can use a code sent to them to check pass/fail status on IBLCE’s website, but they do not get the full breakdown of their results until they receive them in the mail.
For those of you considering taking the test, I urge you to go for it.  It was a scary and huge endeavor, yes, but it was also so very worthwhile.  Just be certain that you are adhering to the new guidelines for 2012 and beyond, and be aware the IBLCE changes them semi-regularly.  For those of you reading this who, like me, are awaiting results, I hope you did a fantastic job, and I raise my hypothetical glass to you.  Based on my experiences, we need driven, passionate, educated people in the lactation world, making a difference for new moms and babies.

 

 
 Star is a breastfeeding peer counselor for a WIC in the Midwest.  She sat the IBCLC  exam for  the first time this summer, and is anxiously awaiting the end of October.   She also sits on the  breastfeeding task force in her town, is helping her  community’s Early Head Start redefine  their breastfeeding support, and is the  driving force behind a local breastfeeding campaign.  In  the remainder of her free  time, she chases around her nursling and preschooler.
Share

Baby Explains- Normal Newborn Behavior

By Diana Cassar-Uhl, IBCLC 

 

Dear Mommy,

Thank you so much for breastfeeding me!  You probably already know that your milk is designed especially for me, and is better than anything else you could feed me.

I know that right now, you feel like your friends who aren’t breastfeeding their babies seem to have an easier time of things.  Those other babies sleep soundly and longer between feedings, they drink so much, and they don’t fuss to eat all the time like I do!  I can tell you’re getting a little bit frustrated, and I hear all the advice you’re getting … my grandma says you weren’t breastfed and you turned out just fine, my daddy says he feels like he can’t do anything to soothe me, and that lady with the cold hands that you call “doctor” gave you a can of something that she says will help me grow faster.  You’re tired and frustrated because taking care of me just seems too hard, but please mommy, before you give up this yummy breastfeeding thing, let me explain some of my behavior to you.  It might help you feel better.

First, if you and I were separated after I was born, for any reason (maybe it was hospital protocol that I be left under a warmer, maybe you were recovering from surgery), I’ve got some catching up to do, because I probably lost more weight than my friends who got to stay close to their mommies.  It’s OK … I’m really good at letting you know when I need some more calories, but it’s important that you let me breastfeed lots and lots, even if my grandma says “he just ate!!”  In my first few days, the nurses at the hospital might tell you I’m hungry and your body can’t make enough milk for me … but mommy, that colostrum from your breasts is some awesome stuff!  It’s packed with protein, which binds to any bilirubin in my body (elevated bilirubin causes jaundice in more than half of newborns) so I can poop it on out.  It’s also a great laxative, which makes it easy for me to get all that black, tarry meconium out of me and we can move on to the seedy, yellow-brown poops that are much easier to clean off my sweet tushie.  Now, the colostrum is really thick and sticky, and I’m so small and still figuring out how to move my tongue, and we’re both still trying to get comfortable together, so it might take me 20 minutes or longer to suck out just ONE TEASPOON (5-7 mL) of that liquid gold.

But it’s OK, mommy!  You know, there is really nowhere I’d rather be than in your arms, hearing your sweet voice and smelling you  — even though you haven’t had a shower since before I was born, you’re just delicious to me.  And something else you should know about me … even though I have a really cute “Buddha belly” that looks all chubby, the capacity of my stomach on the day I’m born is just 5-7 milliliters – that’s the size of a small marble!  You’re the smartest woman in my whole world, so I know you see the connection here!  The amount of colostrum in your breast is exactly the capacity of my tummy!  My stomach walls on my first day of life are very rigid and won’t stretch; this is why, if anyone tries to feed me with a bottle, I’m going to spit most of it back up again, even though I eagerly suck at it.  See, mommy, I only have two ways to send and receive information from my brand-new world – I can cry, and I can suck.  I can’t see much, and all these sounds are so much louder than when I was inside you, and I can use my hands to help me orient myself on your breast, but crying and sucking are pretty much how I make sense of everything.

From the Heart Photography – Tiffany Hileman

I know it seems really confusing, mommy, that I would want to suck and suck and suck even though my tummy is full.  When I suck, lots of great things happen for both of us.  I keep my own digestion moving by triggering the involuntary digestive muscles in peristalsis – moving the contents of my stomach along because I’m still moving my mouth and tongue, which are the beginning of my digestive tract.  When you let me do all this suckling at your breast, I can very easily regulate how I suck, depending on why I’m sucking at any given moment.  You can probably feel when I’m suckling nutritively and swallowing lots of milk, and when I’m kind of relaxed about it, feeding sort of like I’m savoring a bowl of ice cream … you know how sometimes, you scrape just a tiny bit onto your spoon, because you want it to last a long time?  To me, you’re better than ice cream!  But on a bottle, it’s impossible for me to suck and not get whatever’s in there, and that’s confusing to me, so I might keep sucking because that’s what my instinct is telling me to do, or I might realize my tummy hurts (because even on day 10, my stomach capacity is only a ping pong ball) and I’ll cry and cry because all I really know is crying and sucking!

A word about these instincts I feel … I really can’t help it, mommy, that I want to suckle so much.  It’s just how I came out, and there doesn’t seem to be much that I can do about it.  Please believe me, I’m not trying to trick you!  In a few weeks, this need lets up a tiny bit, but for now, suckling is my M.O.  But, do you want to know something really cool?  I’m not the only one who benefits!  When I suckle at your breast in these early days, your body actually activates prolactin receptors!  Isn’t that amazing?  In my first two weeks, the higher I make your prolactin levels go (my suckling triggers a prolactin surge in your body), the more of these receptors get activated in your breasts, and the higher your potential milk production will be for as long as you choose to breastfeed me.  That’s one reason your lactation consultant tells you to wait on introducing that bottle or that binky– this prolactin receptor thing only happens for the first 10-14 days.  After that, the prolatcin surges when I breastfeed are much smaller, so the more receptors there are to gobble up what prolactin is there, the more easily you’ll make all the milk I need.

Besides prolactin, there’s oxytocin, another hormone I activate when I am at your breast.  Oxytocin is part of what makes you so addicted to me!  It’s “the love hormone” and it helps you feel relaxed and content when we’re breastfeeding.  Go ahead, mommy, exhale and relax!  It’s OK!  Oxytocin release is triggered by nipple stimulation, not necessarily milk removal (though when things are going well, my stimulation of your nipples usually means I’m removing milk!).  Now, I know this might sound a little awkward coming from your baby, but I need you to know something about oxytocin.  There are only three events in your life that trigger oxytocin release: nipple stimulation (like when I’m breastfeeding), labor (the oxytocin released during childbirth stimulates uterine contractions, which is why nipple stimulation might be suggested when labor stalls, and also explains why sometimes, after you breastfeed me, you feel an increased expulsion of lochia and maybe some cramping), and … orgasm!!  Isn’t neat that the same hormone plays a part in making me, birthing me, and feeding me, and it’s a hormone that makes you feel GOOD to do all three?

Mommy, I know you are trying your very best for me and you’ve been worried about whether your body can satisfy my appetite.  I know you’re used to being able to measure everything, and your breasts don’t have markers on them to tell you how much milk I got.  Maybe you used a breast pump, and that confirmed your worries that there isn’t much milk there – but mommy, please understand that a good pump can mimic me, but your body wasn’t designed to have all these wonderful hormone surges for a cold piece of plastic with a noisy vacuum motor.  You know that feeling you get when you hold my warmth and weight, smell how delicious I am, and nom nom nom on my fat cheeks?  That feeling helps you make milk!  That feeling is part of the whole system that was designed to make you need to be close to me, just as much as I need to be close to you.  And mommy, I know you’re very busy, and important, and there’s so much you used to do before I came, and I know right now, it feels like you’ll never do those things again, and our house is getting messy, and maybe that scares you.  But please know, every moment you spend holding me, every time you gaze lovingly at me, and every hour you spend breastfeeding me in these early days is so important to me, because you’re all I know.  I love daddy and grandma and all of our friends, but I’m designed to be happiest and least stressed when I’m with you.  Can you wear me in a sling or soft carrier after I’m milk-drunk?  I really like listening to your heart beating while I sleep, and you are warm and soft and smell so good.  That space between your breasts is perfectly sized for my head, and there’s nothing I like better than the feel of your skin against mine.  Well, maybe there is something I like better … I love it when you sleep next to me after we’ve been breastfeeding.  Oh, mommy, when you nurse me while lying down, you relax and your milk flows so nicely, and I feel like you’re so happy to be with me, and I’m very special to you because you don’t have to run off and do something else as soon as I’ve let your breast go.

And mommy, I have a promise to make to you.  I can’t say for sure when it will happen, but there will come a day when I need you a little bit less intensely.  My feedings will get more organized, my weight gain will stabilize, and sometimes, I’ll even like when my daddy or grandma or other loving person holds me.  But today, I need you.  You’ll always be my number one, even after we’re done breastfeeding, but I will learn, like you did, to defer my needs and to trust others to meet them once you and I get a good thing going.  Thank you so much for all you’ve done for me so far. Until you start giving me an allowance, I hope my good health, sweet smiles, coos, and giggles will sustain you!

Love,

Baby


 

Many thanks to the hundreds of readers that shared so many beautiful photos of their newborn babies.  There is just a small sampling here but you all have incredible photographs of your beautiful babies.  Thank you for being willing to share and to all the photographers of these precious images!

 

Diana Cassar-Uhl, IBCLC and La Leche League Leader, has written articles for the La Leche League publications Leaven and Breastfeeding Today, and is the author of the La Leche League tear-off sheet Vitamin D, Your Baby, and You. She is a frequent presenter at breastfeeding education events. Excited about her work toward a Master of Public Health, Diana hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition. Diana, mother to three breastfed children, has served as a clarinetist on active Army duty in the West Point Band since 1995. Diana enjoys running, writing, skiing, and cross-stitching when she finds herself with spare time.  She also writes at Normal, like breathing

 

Share

Nipple Shields: life-saver, supply -wrecker or just another tool for nursing mothers?

 by Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM

I confess, I didn’t know what a nipple shield was back in the day when I was still a very smart but breastfeeding “knowledge- challenged” pediatrician. I did know that whatever they were, they were bad. Very bad. “Never” use them under any circumstances. Ever.

Later, when my niece was born, in a hospital hundreds, nay thousands, or millions of miles away from me, imagine my horror as I found out that she needed a nipple shield to latch. This was bad. I didn’t know why. But it had to stop. So, as unsupportively as I could imagine (in retrospect) I told my sister to stop using that thing! I hadn’t met my niece yet, but I knew that she was less than 5 pounds soaking wet and that nipple thingy was going to ruin her chances of getting into the Ivy League.

One of my dearest friends in the world needed to use a shield when her second child was born. She asked for one when her third was born and was told “no” by the staff caring for her in the hospital. To me, it just was further proof that their use was fraught with problems.

I’m smarter now, at least I’m less breastfeeding-challenged, and I know better than to use the words “never” or “always” and to deny to a request without providing education and informed consent. And I’ve heard too many stories of success to discount the benefits of nipple shields for some mothers and babies. But the fact remains that we have no guidelines for nipple shield use. We have few studies rigorously done that show they are effective.

A nipple shield is a gadget that is placed over the nipple and areolar area. It looks sort of like a nipple (sort of), or a sombrero, but is made of plastic and there are different types. You can get them online and over the counter. The problem with them stems from studies (with flaws in the method in which they were done) that concluded that the use of the shield could decrease milk supply, were associated with more supplementation, and lead to early weaning.

That meant that if they were to be used, the dyad using them would need to be carefully followed, but many mothers were getting them and no follow up was scheduled. I’m not sure the logical result of that should be a compete ban on their use, but, well, they were highly discouraged. Of course, those studies were with older versions of the shield, and other research (with flaws in the method in which they were done) with newer versions of the shield suggested this wasn’t as a big a problem as we thought. But many of those same concerns exist. We honestly don’t know the short-term or long-term effects of nipple shield use.

Nipple shields are often given out in the nursery for “flat” nipples. My guess (no data, so definitely flawed study method) is that the nipples are puffy. And if that’s the case, this might be something to try.

They are often given out for a poor latch as a quick fix to a more complex problem, but we need to remember basics: skin to skin, baby-lead latch, biological nurturing. And asking for help from someone who is board certified in lactation, an “IBCLC.” The shield should not be a first step.

If it’s given to you because your nipples are sore, then in addition to the shield, we need somebody to fix the underlying problem and be your cheerleader and you heal and transition back to the breast. (Find a Lactation Consultant!)

So, suggestions:
If you are given a nipple shield ask why. Informed consent for any intervention means that you are given the required information, in an understandable manner that allows your voluntary participation and that helps in making a decision for a course of action. Questions you can ask to help fulfill informed consent: Why am I getting this thing? How long do I use it? How will it help? Might it hurt? What other things might I try? What type of follow up do I need?

If you are given a shield, and it works, well, cool. You need follow up by somebody who knows something about breastfeeding so we can work on the underlying issue that initially caused the need for the shield.

If you were given a shield and don’t like it, well, let’s get you some assistance and fix whatever the issue is that requires a gadget to fix it so we can go gadget-less.

Shields are meant to be temporary solutions. If you are still using it when your baby is months old, we really should be able to help you stop using it, if you want us to.

If you are given a shield, it works well, you baby is growing and you’re happy but everyone around you is like “ooooooh, those things are bad’ you have my permission to hear everything that that person says after that in the voice of Charlie Brown’s teacher (you remember that voice, or am I showing my age?)

Resources:
Baby led- breastfeeding:http://www.geddesproduction.com/breast-feeding-baby-led.php
Biological Nurturing: http://www.biologicalnurturing.com/
Skin-to-skin http://massbfc.org/providers/SkinToSkin.pdf
Find a lactation consultant: http://www.ilca.org/i4a/pages/index.cfm?pageid=3432

Health professionals’ attitudes and use of nipple shields for breastfeeding women. http://www.ncbi.nlm.nih.gov/pubmed/20524842
Nipple shields: a review of the literature. http://www.ncbi.nlm.nih.gov/pubmed/20807104

 

 

 

Dr. Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM is a general pediatrician and International Board Certified Lactation Consultant in southeastern Wisconsin. Find her sound, evidence-based and helpful advice on parenting at www.drjen4kids.com and Lakeshore Medical Breastfeeding Medicine Clinic.

Share