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Dear Kathleen- Nursing strikes, biting, low weight gain, and painful breastfeeding in pregnancy

We receive hundreds of emails and messages daily from Leakies looking for help and information in their breastfeeding journey.  As so many seek support from us, we are so honored to have the support of Kathleen Huggins, IBCLC and author of The Nursing Mothers’ Companion.  Kathleen is jumping on board with The Leaky Boob to have a regular article answering Leaky questions every month.  The questions will be selected from the huge pool we get in every day to try and help cover the wide range of topics about which Leakies are asking.  These questions are from real moms and represent hundreds of requests for more information in the past few weeks.  Please understand that this is simply the professional opinion of one International Board Certified Lactation Consultant in an informal setting and is not intended to replace the care of a health care provider.  Kathleen is offering support and information, not diagnosing or prescribing treatment.  For your health and safety, please seek the care of a qualified physician and/or IBCLC.  Kathleen does have limited availability for phone or online consultations, see her website  for more information.

Bfing tip low supply sleep on it

Dear Kathleen,

I need help!! I struggled to breastfeed my now 10 month old. After 3 months of struggle we made it and he has been breastfeeding beautifully. I work long hours and pump at work but have had a great supply. I just returned from a 5 day trip where I pumped and dumped and during that time my milk supply went from 24 oz a day to less then 15. Now my baby latches but cries after about 5 min on each side. He calms with expressed milk in a bottle. What do I do now to increase my supply back? I wanted to make it to a year and am heartbroken that I may have to stop sooner!! Help!!

Desperately yours,

Heartbroken for Milk

 

Hi there Heartbroken for Milk,

So sorry about your difficulty.  There are several things you can do.  First of all, I would make sure that you are using the best possible pump, like a Hygeia. If you don’t have a strong pump, you might consider either getting one or renting a clinical grade pump, like a Symphony, or an Ameda Platinum.  I would be sure that between pumpings and nursings that your breasts are being drained at least 7 times each 24 hours.  Having your breasts emptied less than this will keep your supply at the level it is at now.  The other thing I would suggest is More Milk Plus from Motherlove Herbals.  If you go to their website, you may be able to find a local distributor or order it directly from Motherlove.  This herbal product contains fenugreek and three other milk stimulating herbs.  Keep in mind that teas are a weak form of any herb and may not help much.  For a a short while you may also want to nurse before offering solids and once your supply increases, you can offer solids first, but again try to keep the number of nursings remain at a minimum of seven per 24 hours.  If your baby wakes in the night, welcome those nursings for now.

Best wishes too you!

Kathleen

 

Dear Kathleen,

My 10 month old bit me and I yelped, which made her cry. That was 6 days ago and since then she’s completely refused to nurse. She was exclusively breastfed before introducing solids and has never had formula. She won’t take a bottle and will only drink water from a sippy cup. I tried offering expressed breastmilk in an open cup but she wouldn’t have it. I’ve been mixing express breastmilk into her food but that’s all she’s been having. My supply is going and I can only pump a few oz a day. I’ve tried nursing her asleep, warm baths, skin-to-skin, everything, but she still refuses. Everything I’ve read says 10 months is too early to wean and that nursing strikes are temporary, but every day I feel more hopeless. I offer every couple of hours. She has three meals a day. I’m worried she’s missing out on essential nutrition, and even if I had to give formula I don’t know how I’d get it into her. I miss breastfeeding so much, I just want it back. 

Thank you for your help,

Not Ready to Wean

 

Dear Not Ready to Wean,

Tough situation!  At this point, be sure that you are expressing milk at least 7 times each 24 hours with an excellent pump to keep your production high.  You are certainly been doing the right things with co-bathing and lots of skin to skin.  I would offer your milk with an ordinary cup rather than a sippy cup with your guidance and see if she prefers that over the sippy cup.  I would also suggests seeing if she will nurse while asleep or very sleepy maybe while you lie down together in a darkened room.  Final words, hang in there.  Nursing strikes usually end as suddenly as they begin!

Good luck!

Kathleen

 

Dear Kathleen,

My son is 8 1/2 months and exclusively breast fed, and the last couple months has a side preference when he wants to relax or fall asleep. He has 6 teeth and is still in the teething process. My problem is, he bit his preferred nipple 3 times in 24 hours, drawing blood the first couple times. Now, I am trying to give it some time to heal, but he has a total meltdown when I don’t let him nurse on that side! 

Any suggestions to help him through this while I attempt to heal would be much appreciated! 

Sincerely,

Wounded Nipple

 

Dear Wounded,

I hope that you are expressing your milk very often with an excellent pump, at least 7 times each 24 hours.  I would also suggest feeding on that side using other positions that irritate the wounded nipple less, like “football” hold or having him straddle your thigh and then come onto the breast.  If the nipple is open after 5 days, it may then be time for an antibiotic as bites can easily become infected and then not only are they slow to heal, but you can also develop mastitis.  There are other healing remedies like Motherlove’s Nipple Cream which you may be able to find if you visist Motherlove’s website.  It contains several healing herbs and can work quickly unless there is already bacteria in the wound.  Also, you may want to learn more about biting.  If you visit my website, Kathlenhggins.com, I have a blog about “biting”.  This needs to stop!

Kathleen

 

Dear Kathleen,

I still breastfeed my just 2 year old and am 15 weeks pregnant. Breastfeeding is now VERY painful contributed by a very poor latch I think (there are teeth marks left behind on my nipples). It is no longer pleasant for me and I find myself feeling anger and resentment during feeding. The problem is my toddler is not ready to stop, she feeds on waking and before sleeps so it in entrenched in those routines. No amount of distraction, food or drink offerings or cuddles can stop endless sobbing and clawing at me. I’m at a loss.  

Thank you, 

Unpleasant Breastfeeding

 

Hi Unpleasant Breastfeeding,

There are a few things you can try.  First of all it is very common for nipples to be tender during pregnancy.  They may improve as your pregnancy continues.  With that and the marks from your toddlers teeth, it is no surprise that you are suffering through nursings!  There is nothing that can be done about your pregnancy nipple soreness, but you can help the problem with your toddler’s latch. Because the baby’s mouth tends to drag down the breast tissue, it may be important to lift her upwards by using a pillow and lifting your breast upward.    Experiment with other nursing positions to see which positions are more comfortable and which  avoid letting her chin rest on her chest, trying to get her head tilted back a little more.  Try and offer your breast with the nipple pointing downward and wait for a wide open mouth before latching. Feel free to use lanolin after nursings.

With all that being said, if you are still wanting to stop nursing, you can do that too! If you are only nursing in the morning and just before sleep, you and your partner can both help out.  She really is mostly weaned at this point!

For now, I would suggest tackling just one nursing at a time.  When she wakes, start of new routine of an early breakfast and some sort of play or other activity. Without telling her  “No”, let her know you are “saving the milk” until nap time, using whatever words she understands. Think of all the things she loves to do and substitute any of those things, Once you have that morning one gone, pick another, maybe the nighttime or nap time nursing. One the week-end, or in the evening, let your partner work his magic, with you out of sight.  Go take a walk. Perhaps Dad can help her off to sleep at night by making a new routine, like reading a book and rocking him for awhile.   A bath, a story and more rocking can certainly be a new way to distract her and soon you will have weaned. On the other hand, maybe one nursing a day is pleasant for the both of you.

See how changing the latch works. Move slowly on this, taking the nursings out just one at a time over a period of time until you are feeling better and she is adjusting.

Best wishes!

Kathleen

Dear Kathleen,

I have a soon to be 5 months old infant who is breastfed since birth and the biggest challenge is his weight, he only weighs less than 13 lbs and his birth weight was 6 lbs 12 oz. I’ve fed him every 2 hours and now sometimes 3 hrs to 4. When I pump I only produced 2 oz total from both breasts which the pediatrician isn’t happy and is very concerned that he’s probably not getting enough milk.  He spit up a lot, lots of urinations and some common bowel movements but his doctor isn’t satisfied and we keep having to go back for a weekly or biweekly weight check and now the doctor wants me to start giving him rice cereal now which I’d rather wait til he is 6 months old so I dont know what to do.  I don’t want to do formula. This is my 4th child and my 3rd child to breastfeed.  With my last 2 children I breastfed and did produced good amount of milk but this time I’m not sure if I’m producing enough milk which is very discouraging for me.  I took fenugreek for 3 months but I wished I had known I should have taken blessed thistle along with fenugreek.  Any suggestion on how I can increase my milk supply? Could it be his latch?  It still hurts when he latches on and sucks on my nipples.  I’m trying to stay positive but I feet like a failure that my baby is probably not getting enough milk from me because of his very low weight for his age.  With my other two nurslings I had a wonderful lactation consultant but that was 7 years ago and we have moved, I don’t even know how to find a good consultant.  Please help!

Yours truly,

Worried but hopeful

 

Hi Worried,

It’s understandable that you are worried, when I plot out your baby on the World Health Organizations Breastfed Infant Growth Charts, which you can find on line, I see that we was born on the 15th %tile and he seems to now be on the 3rd %tile.  I think you can offer him more calories without having to resort to formula.  I don’t know when you are pumping in relation to a nursing, so that doesn’t help me much.  Your baby needs more milk which has more calories, so I agree that cereal is not the answer.

I would suggest a few things.  First of all, you need to aim for 7-8 nursings each 24 hours. I would not allow the baby to go without nursing for 3-4 hours.  Watch for early hunger cues, like finger sucking and offer your breast whenever you notice this.  If your baby uses a pacifier, I would put it away.  Welcome night time feedings as mothers produce more milk in the night time.  If he sleeps through the night, I would wake him before you go to bed, or even wake him after five hours of sleep.  During the day and evening, I would try and double pump after most of these nursings for 5-10 minutes and offer him that milk after the next nursing.  This milk will be very high in calories and help him gain more weight.  While not knowing what pump you have, be sure that it is a good one, like a Medela or Hygeia or you could even rent a clinical grade pump for awhile if you have doubts about the pump you are using.  If your nipples are larger than a penny, be sure to use a larger sized flange, like a size 27mm.

Next, I would add a strong herbal galactagogue, like More Milk Plus from Motherlove Herbals.  If you go to their website, you may be able to find a local distributor or order it directly from Motherlove.  It contains, fenugreek, Blessed Thistle, and two other milk stimulating herbs.  It usually takes 48-72 hours to kick in.  A second herb you can add is GoLacta.  Go to their website for ordering information, Using both of these together can really boost your supply.  At this point, I would like to see a daily weight gain of 1/2 ounce per day.  That is normal for this age.

If your periods have already resumed, you may see that your supply lessens between the time you ovulate and when your period resumes.  If that is the case, you can take 1000 mgms of Calcium and 500 mgms of magnesium every day until your period starts.  I am assuming that you are not on any estrogen containing birth control which definitely lessens milk supply,

If your baby is spitting up, that suggests reflux to me which can cause some babies to limit their nursings.  I would avoid any of the following the following foods and beverages; these include chocolate, all citrus fruits and their juices (including strawberry, pineapple and kiwi), the gassy veggies like onion (onion powder), garlic (garlic powder), peppers, cucumbers, cauliflower, cabbage, broccoli, and Brussels sprouts.  It may be your baby is reacting to the foods you’re eating, eliminating the most likely culprits first and then testing them by adding them back one at a time could help you figure out if one of these are the cause.  If this baby has the same Daddy as the others, and they had colic symptoms, you might also consider a trial off of all cow milk products for a short while to see if that helps with the spitting up.  Cow milk products can be an allergen which runs in certain families.

Lastly, if you want to find a lactation consultant, go to ILCA.org and scroll down to “Find a Lactation Consultant”, enter your info and some name should pop up.  If you have private insurance, they should cover the cost.

Best wishes to you and your baby!

Kathleen

Kathleen-HigginsKathleen Huggins RN IBCLC, has a Master’s Degree in Perinatal Nursing from U.C. San  Francisco, founded the Breastfeeding Warmline, opened one of the first breastfeeding clinics in  the United States, and has been helping breastfeeding mothers professionally for 33 years.  Kathleen  authored The Nursing Mother’s Companion in 1986 followed by The Nursing Mother’s Guide to Weaning.  Kathleen has also co-authored Nursing Mother, Working Mother with Gale Pryor, Twenty Five Things Every Breastfeeding Mother Should Know and The Nursing Mothers’ Breastfeeding Diary with best-friend, Jan Ellen Brown.  The Nursing Mothers’ Companion has also been translated into Spanish.  Mother of two now grown children, Kathleen retired from hospital work in 2004 and after beating breast cancer opened and currently runs Simply MaMa, her own maternity and breastfeeding boutique.  She continues to support breastfeeding mothers through her store’s “breastaurant,” online at The Leaky Boob, and in private consultations.  
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Dear Kathleen- on nipple damage healing and pumping

We receive hundreds of emails and messages daily from Leakies looking for help and information in their breastfeeding journey.  As so many seek support from us, we are so honored to have the support of Kathleen Huggins, IBCLC and author of The Nursing Mothers’ Companion.  Kathleen is jumping on board with The Leaky Boob to have a regular article answering Leaky questions every month.  The questions will be selected from the huge pool we get in every day to try and help cover the wide range of topics about which Leakies are asking.  These questions are from real moms and represent hundreds of requests for more information in the past few weeks.  Please understand that this is simply the professional opinion of one International Board Certified Lactation Consultant in an informal setting and is not intended to replace the care of a health care provider.  Kathleen is offering support and information, not diagnosing or prescribing treatment.  For your health and safety, please seek the care of a qualified physician and/or IBCLC.  Kathleen does have limited availability for phone or online consultations, see her website for more information.

Dear Kathleen,

My nipples are a wreck following a shallow latch and then thrush with my 8 week old.  After working with an IBCLC that helped fix my daughter’s latch and take care of the thrush, things are improving.  However, my nipples are still cracked and bleeding and I think they just need a break to heal.  The IBCLC I work with suggested I just pump for a little bit until I’m healed and I’m ok with that.  I feel like I’m a bit lacking in the pumping department though and only got 4 ounces the first time I tried with a hospital grade double electric pump and my daughter downed that pretty quickly.  How often should I be pumping to keep up my supply?  How long should I expect healing to take?  How do I pick a bottle that won’t encourage my daughter to prefer the bottle over me?

Thank you so much for your help!

Sore Nipples 

 

Hello Sore Nipples!  I am so sorry to hear that you are still struggling at this point in time! Sounds like you have been through a rough go.  Yes, you and your L.C. are on the right track.  A break from any more trauma is certainly in order.  I am happy to hear that you have a clinical grade pump.  I do hope you have the right size flanges for more comfortable pumpings and for removing the most amount of milk possible.  If your nipples are swelling very much in the tunnel, I would suggest getting the next size flange for more comfortable and effective pumping. Another product, “Pumping Pals”, slipped into any flange, makes pumping even more comfortable and for some moms even more efficient.  You might want to visit their website to see what I mean.  The company is very helpful in getting you the right size flanges to use in your kit and they are fairly inexpensive. With that being said, still many pumps still leave quite a bit of milk on the breast.  For that reason, I suggest “Hands-on Pumping”, that is using your hands to help remove the most milk possible at each pumping.  Please watch Dr. Jane Morton on Stanford University’s website on breastfeeding issue and see her mini-lecture and video of hands-on pumping.

I would like to talk to you more about the condition of your nipples.  If your nipples are still cracked, I would like you to consider treating them with an oral antibiotic.  Mothers with injured nipples longer than 5 days are at a much greater risk of developing mastitis; 75% of moms with open nipples go on the develop a breast infection because of the bacteria in the open areas.  And this seems much more common during the cold weather months.  There was a great study done by two Canadian physicians some time ago that showed the consequences of wounded nipples that were untreated leading to mastitis.  Also, nipples are more difficult to heal when they are infected with bacteria.  For both of those reasons, I suggest speaking with your midwife or doctor about getting treatment for at least 10-14 days.  I don’t think most doctors are aware of this connection, but with your nipples being in this shape so late in the game, I am convinced they are colonized with bacteria.  Yes, I am sure that this makes you worry about yeast, but yeast is much easier to treat than a case of mastitis, which can also lessen your overall milk production.

Mastitis risk with damaged nipples

I do think that getting 4 ounces is about what a baby at this age requires at each feeding.  You will want to aim for about 8 pumpings each 24 hours.  If you are not getting at least 3-4 ounces when you pump, you may want to also consider using some herbs.  You can use fenugreek capsules that are available at most any health food store, 3 caps three times a day. This is probably different that the dose given on the bottle.  I actually find that mothers do quite well using Mother Love’s More Milk Plus, a combination of milk stimulating herbs.  You can visit their website and see if there is a local distributor or order them on-line directly from Mother Love. Nursing teas are a very weak form of any herb, so I don’t recommend them as the primary way to stimulate higher milk production.

Babies typically down a bottle in no time flat and may still act hungry!  This can lead parents to believe that the baby may need more milk.  Four ounces with a slow flow nipple, might help some but keep in mind that many nipples that are labeled as slow flow, really aren’t!  Hopefully, the baby takes 5-10 minutes to drink 4 ounces of milk. There is an old saying, “It takes 20 minutes for the brain to know when the stomach is full!”  So true!  If you are very worried that the baby will come to fall in love with the bottle flow, you might reconsider and have one nursing every 24 hours, but I leave that to your discretion. I think for most babies, if there is a healthy supply of milk, they should return to the breast without too much of a problem.

I wish you every success and very soon!  You are quite a determined mom!

Best wishes,

Kathleen

Kathleen-HigginsKathleen Huggins RN IBCLC, has a Master’s Degree in Perinatal Nursing from U.C. San  Francisco, founded the Breastfeeding Warmline, opened one of the first breastfeeding clinics in  the United States, and has been helping breastfeeding mothers professionally for 33 years.  Kathleen  authored The Nursing Mother’s Companion in 1986 followed by The Nursing Mother’s Guide to Weaning.  Kathleen has also co-authored Nursing Mother, Working Mother with Gale Pryor, Twenty Five Things Every Breastfeeding Mother Should Know and The Nursing Mothers’ Breastfeeding Diary with best-friend, Jan Ellen Brown.  The Nursing Mothers’ Companion has also been translated into Spanish.  Mother of two now grown children, Kathleen retired from hospital work in 2004 and after beating breast cancer opened and currently runs Simply MaMa, her own maternity and breastfeeding boutique.  She continues to support breastfeeding mothers through her store’s “breastaurant,” online at The Leaky Boob, and in private consultations.  
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IBCLCs, Negative Experiences, and Self-Advocacy

 

 

This post made possible in part by the generous support of Boba, makers of the Boba Baby Carrier.

Jessica and Sugarbaby Bfing

When my daughter was entering the 2nd grade at our local public school, we were all enthusiastic about the coming year.  She loved school, loved learning, loved everything about it.  But just a few short weeks into the school year things we drastically different.  She cried all the time, she hated going to school, she started struggling with school work, and every day she complained that her tummy hurt and she was too sick to go to school.  We were confused.  What had happened to our little girl?

It quickly became apparent that while there were multiple issues going on that I won’t go into here except to say there were some technical difficulties and an adjustment period that needed to happen.  Still, there was one particular issue that emerged as being critical: she didn’t like her teacher.  Believing we need to encourage her to work with people, even ones she didn’t like, The Piano Man and I tried to help her navigate this relationship.  This proved to be more challenging than we expected because, as it turned out, we didn’t like her either.  She simply wasn’t the kind of person we thought would be teaching second grade.  Or teaching at all.  Grough, grumpy, rarely smiled, she came across as cold and distant.  Suddenly, challenges our daughter had previously felt empowered to tackle loomed as impossible mountains.  Intimidated by the one she thought was there to guide and support her in facing these challenges, she withdrew and began to give up.

We tried to work with the school and the teacher but in a short amount of time we felt we needed to explore other options and ended up transferring schools.  It was that, or risk killing our daughter’s love for learning and that simply wasn’t something we were willing to sacrifice.

When we visited the new school Earth Baby was nervous about meeting the 2nd grade teacher.  Gripping my hand she whispered “I don’t like 2nd grade teachers, they are mean.”  I was surprised she had already jumped to a conclusion about a group of people based on her experience with just one of that group.  Given that she was 7 at the time, I probably shouldn’t have been surprised at such an immature response but I felt that we had worked hard to help our children understand how individuals can be so different.  Encouraging her to remember that Miss B. would be a person first, a 2nd grade teacher second, we met with the teacher.  Gentle, kind, friendly, and very warm, Miss B. proved to be the opposite of the previous 2nd grade teacher and Earth Baby ended up flourishing in her class.  Inspired with hope and confidence, Earth Baby made a lifelong friend in her teacher (and is seeing her this summer) and not only met but surpassed her goals for the year with an enflamed love of learning.  Interestingly enough, now she will talk about how wonderful 2nd grade teachers are and being a teacher is in her top 5 career options.

Why am I sharing this story on a breastfeeding site?  Moms often come to TLB looking for breastfeeding support. The support they are looking for is usually just about what is normal in breastfeeding journeys, the mom-to-mom support of experience and camaraderie.  Sometimes it’s for issues that are outside of normal and require more expertise support and help.  It isn’t uncommon for a Leaky and/or one of the admin to recommend seeing an IBCLC (International Board Certified Lactation Consultant) for experienced and trained support.  These experts are usually the most equipped to help moms with true lactation problems having gone through intense training and having to comply to regular board standards in their continuing education and certification.  Just as often, someone then shares their negative experience with an IBCLC.  Frustrated and hurt, these women sometimes share that an IBCLC almost ruined their breastfeeding relationship with misinformation, intimidating and overwhelming directions, and sometimes down right bullying.

Find the right IBCLC

From these comments it sometimes sounds as though they fear all IBCLCs will be just like the negative experience they had.  Hurt and discouraged by the one or two individuals they encountered in the profession, they are unsure they can trust anyone with the title and position.  Like my daughter felt unsure about 2nd grade teachers, these moms are skeptical of the entire IBCLC profession, not because they don’t know that they are all different people but because they may believe that what they didn’t like is actually expected to be a part of the profession.  As if the consultants are trained to support that way.  Just as with any profession, there are individuals within the lactation consultant profession that are rude, unsupportive, not helpful, judgmental, dismissive, and misinformed. Thankfully, most I’ve met go into supporting breastfeeding moms because they genuinely care and want to help moms reach their breastfeeding goals.  The IBCLCs I’ve interacted with understand the vulnerable nature of that time in a mother’s life and the importance of providing the right kind of support.  Most IBCLCs aren’t in the profession to push an agenda or tell moms what to do, they genuinely seek to provide legitimate support unique to each mothers’ needs.  Sure, I’ve met a few that seemed burned out and dogmatic just like my daughter’s first second grade teacher, but just like most 2nd grade teachers actually enjoy children and teaching, so most IBCLCs aim to provide sincere information and assistance.  I encourage moms that need lactation support to move on from someone that isn’t supportive to find someone that’s a better fit.   It’s that, or risk not reaching your breastfeeding goals and that simply isn’t something we should be willing to sacrifice without a fight.

I am aware that for many, a second choice, let alone a third or fourth, isn’t readily available.  Financial restrictions, local availability, and even cultural support from family and friends can make it difficult to find someone.  Sometimes, shoot, maybe often, the support you need will find you in unexpected places such as the internet or a new friend.  Moms may have to try other paths for lactation support such as virtual appointments via the web or attending a local breastfeeding support group or even reading articles online.  Whatever it takes, pushing on to find the support you need may be work but you and your baby are worth it.

You don’t have to be stuck with a professional providing inadequate support.  In the end, you are the biggest advocate for you and your child and if advocating for you both means moving on to find the assistance you need, you won’t regret doing so.  As Leaky and IBCLC Jackie Rauch shared:

I will sometimes tell my clients the story of me seeking her out just to let them know that even the people with the knowledge need to seek out help from people with the knowledge. If you are not getting the help you need, keep looking!

You never know, you may find the one that helps you turn it all around and inspires you with hope and confidence.

Need a lactation consultant?  This site can help you find one.

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What about you?  What has your experience with an IBCLC or other lactation professional been like?  Did you have to find someone else for better support at some point?  Did an IBCLC or other lactation professional help you in your breastfeeding journey?  Check out the conversation we’re having on this very topic over on The Leaky [email protected]@b Facebook page

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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. 

 

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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.
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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.
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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.

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