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Weaning the Breastfed Baby

January 29, 2013 by
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?

_________________________

 

 

 

 

 

Filed Under: Article, Articles from the professional experts, Breastfeeding, extended breastfeeding, Featured, Relational Resource, Weaning, Weaning Tagged With: , , , , ,

Do we have thrush?

July 11, 2012 by

by Tanya Lieberman, IBCLC, sponsored by Motherlove Herbal Company.

Having thrush is be painful and frustrating.  And trying to figure out if you have thrush can be confusing.  Here’s our guide* to aid in determining whether you and your baby have thrush. 

Please note that we are not discussing treatment options in this post. For information on treatment please see Dr. Jack Newman’s Candida Protocol.

 

What is thrush?

Candida albicans is a fungus lives in our bodies.  Some conditions such as antibiotic use and illness can cause it to grow out of balance, and this overgrowth can cause painful infections, generally in moist areas such as the mouth, nipple area, vagina, and diaper area.

 

How is thrush diagnosed?

Diagnosing thrush is difficult, because skin tests are considered unreliable, and the results aren’t available for several days – a lifetime when you have pain!  Most doctors diagnose thrush based on symptoms and not diagnostic tests.  So you may hear that thrush is diagnosed through treatment – if it responds, it must have been thrush!

 

What makes me more likely to have thrush?

You and your baby may be at higher risk for thrush if you or your baby have recently used antibiotics (often used for a cesarean birth), have been ill, or perhaps have been in a very warm and moist environment.  Thrush takes time to develop, and may not be obvious until a few weeks after this trigger, so pain in the first week or so after your baby is born is unlikely to be thrush, and is much more likely to be caused by a shallow latch or one of the other causes mentioned below.

 

What symptoms are strongly associated with thrush?

Mother symptoms:

One study of mothers between 2 and 9 weeks postpartum found that mothers who have two or more of the following five symptoms are likely to have thrush.  Having three or more makes it even more likely.

  • shiny or flaky skin of the nipple/areola
  • burning pain on the nipple/areola
  • sore (but not burning) nipples
  • stabbing pain in the breast
  • nonstabbing pain in the breast

 

And a mother is highly likely to have thrush if those symptoms include:

  • shiny skin of the nipple/areola with stabbing pain, or
  • flaky skin of the nipple/areola in combination with breast pain

 

The study also found that mothers were likely to have symptoms on both breasts, though sometimes not right away.

 

Baby symptoms include:

  • White patches on the baby’s cheeks, gums, palate, tonsils, and/or tongue.  If you try to wipe off these patches they will appear “stuck” there, and may bleed.
  • A yeast diaper rash, which may be red or red with raised dots

 

Can you have yeast inside your breasts? 

Shooting and/or burning pain deep inside the breast is sometimes diagnosed as intraductal thrush – thrush in or around the milk ducts inside the breast.  This diagnosis is controversial, as recent research has found that mothers with suspected yeast infections may actually have bacterial infections or Raynaud’s vasospasm, and that yeast hasn’t been cultured in the milk of mothers with suspected interductal thrush.

 

If it isn’t thrush, what could it be?

Other causes of pain which may make you suspect thrush:

  • Shallow latch
  • Raynaud’s Phenomenon
  • Bacterial infection
  • Mastitis
  • Skin problems such as eczema, psoriasis, dermatitis

 

My baby’s tongue is white.  Does that mean he has thrush?

Babies’ tongues normally have a white coating.  This in itself is not an indication of thrush.  If your baby has white patches on the inside of his cheeks or gums (if you try to wipe them off they may look red or bleed), this is an indication of thrush.

 

My doctor said that my baby doesn’t have white patches in her mouth, so we couldn’t have thrush.  Is that right?

Some babies who have thrush do not have white patches in their mouths.  Some may have a yeast diaper rash and no symptoms in their mouths.

 

I was treated with Nystatin and it didn’t work.  Does that mean I don’t have thrush? 

Nystatin is ineffective at treating thrush in an estimated 68% of cases.  So if the symptoms didn’t go away using it, you may still have thrush.  Consult this guide to thrush treatment for other treatment options.  See this study for more information on the use of Nystatin in treating thrush.

 

My doctor said that since I have symptoms but my baby doesn’t, she doesn’t need to be treated.  Is that right?

If thrush has been diagnosed in either of you, you both should be treated to prevent recurrence.

 

I keep getting thrush over and over.  Could it be something else?

If you have repeated cases of thrush, or if treatment doesn’t resolve your symptoms, you may want to explore whether your symptoms are caused by some other problem instead or, or in addition to, thrush.

 

I think I have thrush.  What should I do now?

Contact your health care provider and explain your symptoms. You may also wish to consult this guide to thrush treatment.

 

*This information is provided for educational purposes only, and should not be construed as medical advice.  For care suited to your own situation, please consult your health care provider.

 

References: 

 

Mohrbacher, Nancy.  Breastfeeding Answers Made Simple: A Guide for Helping Mothers.  (Amarillo: Hale Publishing, 2010), pp. 652-53

 

Jimi Francis-Morrill, M. Jane Heinig, Demosthenes Pappagianis and Kathryn G. Dewey.  “Diagnostic Value of Signs and Symptoms of Mammary Candidosis among Lactating Women,” J Hum Lact August 2004 vol. 20 no. 3 288-295

 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.
Filed Under: Article, Articles from the professional experts, Featured, Relational Resource, Thrush Tagged With: , ,

Bottle Feeding Breastfed Babies

March 1, 2012 by

 

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.

 

Filed Under: Article, Articles from the professional experts, Bottle Feeding, Featured, formula, guest posts, Relational Resource, Supplementing Tagged With: , , , , , , , , , , , , , , ,

Your Guide to Relactation

December 13, 2011 by

 

Stopped breastfeeding and want to start again?  Here’s our guide to relactation.

What is relactation?

Relactation is re-establishing breastfeeding after stopping breastfeeding, or after a period of very little breastfeeding.

Why would I want to relactate?

Mothers decide to relactate for many reasons, but most want either to resume the breastfeeding relationship, or provide more breastmilk, or both.

What are my odds of successfully relactating?

There is little research on relactation, but the available studies strongly suggest that, with proper support, most mothers can partially or fully relactate.  Below are some studies that offer some encouraging findings about the success of relactation.  It’s important to bear in mind that in most of these studies mothers received help in relactating from trained breastfeeding support people.

One study of 139 Indian mothers who had stopped breastfeeding for at least ten days found that 84% were capable of either full or partial relactation:

  • 61% fully relactated
  • 23% partially relactated (formula supplements reduced by half)
  • 16% were unable to relactate

A recent survey of 84 relactating mothers of infants (on average, 2 months old) in Korea found:

  • 75% of mothers fully relactated (defined as 90% or more breastmilk feedings)
  • 25% of mothers either partially relactated or did not relactate

An older survey of 366 U.S. mothers, mothers reported that:

  • More than 50% established full production within one month
  • 25% required more than one month to establish full production
  • The remaining mothers breastfed with supplements until their babies weaned

A study of 50 mothers of hospitalized infants under four months old, found:

  • 92% of mothers fully relactated
  • 6% partially relactated

 

What factors will influence my success in relactating?

The research on relactation confirms what you might already suspect.  The following factors are associated with more success at relactating:

  • A younger baby
  • A shorter gap between weaning and relactating (sometimes called a “lactation gap”)
  • The willingness of the baby to take the breast
  • Having assistance from trained breastfeeding support people

These factors may influence your chance at meeting your goals, but each mother/baby pair is different, and relactation may still be possible even you don’t meet the most favorable criteria.

 

How long will it take?

Based on the research above, Nancy Mohrbacher, IBCLC, in Breastfeeding Answers Made Simple, recommends that mothers plan for relactation to take one month.

 

How should I measure success?  What goals should I set?

You may want to spend some time reflecting on your motivation for relactating.  Is it important to you to provide as much breastmilk as you can?  To have the feeling of closeness you have with breastfeeding?

You might set a goal of full breastfeeding, or you might set a goal of partial or any breastfeeding.  Some moms, who don’t think that their babies will return to the breast, set a goal of pumping and providing as much breastmilk as they can by bottle (exclusive pumping).  Some mothers want the breastfeeding relationship back, and aren’t concerned with how much milk they provide.

Interestingly, one survey of relactating mothers found that “Milk production was less often a goal and, when so specified, it was likely to influence the mother to evaluate her experience negatively and to result in difficulty in achieving a total milk supply.”

There is no right or wrong way to set goals for relactation.  And you may not want to set any goals at all.

 

How do I relactate?

There are two, related parts to relactation:  bringing back a milk supply, and bringing the baby back to the breast.  These are interrelated projects, as the best thing for your milk supply is to have a baby nursing frequently, and a baby is more likely to return to the breast if there is plenty of milk there.

But the first, and probably the most important thing, is to seek some support.

Get support.

We strongly recommend seeking out sources of support for this process.  As we note above, the mothers in the studies cited above were typically receiving skilled help with relactation, and this may have influenced their success rates.

You may want to consult with a lactation consultant (IBCLC), La Leche League leader, a breastfeeding-friendly pediatrician, or other trained breastfeeding support person (see links at the end of this guide for sources of support).  A well-trained support person can help you uncover reasons why breastfeeding stopped, troubleshoot as you work on relactating, and connect you with good resources to help you meet your goals.

Trained help is important, but don’t underestimate the power of support from other moms, family, and friends.  Having more people on your team can make a big difference in breastfeeding success. You may find attending a La Leche League or other support group meeting helpful.  WIC breastfeeding peer counselors are another good source of mom-to-mom support.  You may also want to discuss your goals and motivation with some friends or family members (especially your partner), and ask for their support and encouragement.  Relactation requires time and effort, and having support is key.

Explore what happened.

It helps to explore why breastfeeding stopped.  If it was a problem with basic breastfeeding management (poor advice, infrequent feeding, etc.), relactation may be a simple project of restarting what you were doing before.  If breastfeeding ended because, in spite of “doing everything right,” you didn’t produce enough milk, and your baby became unwilling to breastfeed, there are more issues to explore.  If you stopped because of pain, learning more about latch, and exploring the possibility of issues like tongue tie, are worthwhile topics to consider.

You may find it helpful, particularly in cases of unexplained milk supply problems or behavior in your baby, to explore these issues with a lactation consultant (IBCLC).  You’ll find a link to find one at the bottom of this guide.

Bring back your milk supply.

Empty your breasts frequently.  If your baby is willing to nurse, feeding frequently is the single most effective thing you can do.  Aim for at least 10-12 feedings every 24 hours.  Feed on both sides, and feed long enough to drain each breast well.

If your baby isn’t taking the breast, or is doing so infrequently, use a pump to stimulate your milk supply.  Ideally you should pump at least every three hours (though many mother find it more manageable to take a break at night).  Double pumping provides more stimulation than pumping one side at a time.

Ensure effective feedings.  If your baby is nursing, make sure that he or she is taking the breast deeply into the mouth, and that you feel comfortable when nursing.  A shallow latch and/or pain can mean that your baby isn’t feeding as effectively as possible.  Get help correcting this from a trained breastfeeding support person.

Pump after feedings.  If your baby is nursing, try pumping after feedings with a hospital grade breastpump.  Since milk supply seems to be calibrated based on how empty your breasts get, pumping after feedings can be an effective way to increase milk supply.

Use breast compression. When nursing and/or pumping, use breast compression to fully empty your breasts and keep your baby engaged while nursing.  This is a particularly effective way to get good feedings with a baby who is sleepy at the breast.

Consider a supplemental nursing system (SNS).  Using an SNS allows a baby to receive formula supplements at the breast while stimulating your milk production by nursing.  There is also some evidence that substituting feeding methods other than bottles – such as cup, spoon, SNS – increases the chances of relactation success.

Use the power of skin.  Holding your baby skin-to-skin (your baby in just a diaper on your bare chest) boosts your milk making hormones.  And it feels great!

Take a galactagogue.  There are both herbal supplements and prescription medications which increase milk supply.  Some herbs are particularly helpful with glandular and hormonal causes of low milk supply.  Consult with a lactation consultant and/or your health care provider about which may best suit your needs.

Bring your baby back to the breast.

Get skin-to-skin.  Skin-to-skin contact is immensely powerful in establishing breastfeeding, and it can significantly aid the process of relactation.  Hold your baby (wearing only a diaper) on your bare chest as often as you can.  You may find that he or she begins to self attach (see next point).

Use Baby-led Breastfeeding, Laid Back Breastfeeding positions, and co-bathing.  Research is increasingly pointing toward the importance of baby’s innate feeding instincts in the establishment and re-establishment of breastfeeding.  Babies are able to crawl, scoot, and wiggle their way to the breast all on their own from birth, and new research is showing that babies retain this instinct long after the newborn period.  Baby-Led Breastfeeding involves positioning babies in a way that allows them to crawl to the breast.  Biological Nurturing, or Laid-Back Breastfeeding, involves reclining to breastfeed.  See more about the Laid Back Breastfeeding position and its ability to take advantage of babies feeding reflexes.  Some lactation consultants have also found that taking baths with your baby (called remedial co-bathing) can help in re-establishing breastfeeding.

Ensure a good latch.  As mentioned above, a deep latch will allow your baby to receive the most milk, and will keep you comfortable.  Seek help from a trained support person if getting a good latch poses a challenge.

Breast compression.  Keep your baby engaged at the breast by squeezing your breast when your baby is nursing.  This is particularly effective if your baby is sleepy at the breast.

Consider a nipple shield.  Some babies who have had many bottle feedings will nurse if the mother uses a nipple shield, as it makes the breast feel more like a bottle.  For some babies, it can be hard to wean from nipple shields.  Seek help from breastfeeding support person for assistance in using and weaning from a nipple shield.

Use a supplemental nursing system.  SNS can persuade babies to return to the breast because they get a greater flow when they nurse.  And as noted above, they can help increase milk supply by keeping all sucking at the breast.  Seek help from breastfeeding support person for assistance in using one.

Focus nursing around strategic times.  Try nursing when supply is higher, such as nighttime and morning.  Offer the breast for comfort when you know that your baby is already full, or when your baby is sleepy.

Consider pre-feedings.  Some babies will nurse if the “edge” has been taken off their hunger.  Try giving your baby an ounce of formula just before attempting a feeding at the breast.

Ensure that your baby continues to thrive.

If you are reducing formula supplements while relactating, we’d suggest:

  • Reducing formula supplements gradually.  Kelly Bonyata, IBCLC, of kellymom.com recommends initially reducing formula supplements by one ounce per day (not per feeding).
  • Doing frequent weight checks to ensure that your baby continues to grow normally.  Checking for swallowing and monitoring diaper output can also provide some information about your baby’s intake.

 

What are some good resources for more information and support?

  • Lowmilksupply.org.  Comprehensive online source of information on increasing milk supply
  • KellyMom.com:  Relactation and Adoptive Breastfeeding:  The Basics

 

 

 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.

This resource page was made possible by Motherlove Herbal Company.

 

Filed Under: adoptive breastfeeding, Article, Articles from the professional experts, Breastfeeding, breastfeeding difficulties, breastfeeding help, Featured, relactating, Relational Resource Tagged With: , , ,

Help, my milk supply is low! Or is it?

October 3, 2011 by
By Tanya Lieberman, IBCLC

Ever wish your breasts had little ounce markings? If so, you’re not alone. One of the more confusing things about breastfeeding is determining how much milk you’re making. You can’t see how much is going into your baby, so how can you tell if your milk supply is enough for your baby?

On this page we share the best ways to determine if your milk supply is in fact low, and describe the many things that can make you think that your supply is low when it actually isn’t.

 

Below are some normal experiences that can trick you into believing that your supply is low:

“My baby wants to eat all the time.” It’s normal for babies to eat frequently, generally in the range of 8 to 12 times in 24 hours for many months. This means many hours of feeding a day, and it may feel constant at times. It’s also normal for babies to “cluster feed” at times during the day. If your baby is feeding significantly outside of the 8-12 times range, contact a lactation consultant or other breastfeeding support person.

“My breasts feel softer than they used to.” Toward the end of the first month of breastfeeding many women notice that their breasts have decreased from the size they were when their mature milk came in. This is normal, and does not indicate anything about milk supply.

“I don’t feel that ‘let down’ sensation.” Some women have a “let down” sensation when they make milk, and some don’t. It doesn’t seem to have any bearing on the amount of milk a mother makes, so don’t worry if you don’t feel anything.

“My baby suddenly wants to eat all the time.” Babies go through growth spurts. They do this in order to increase your milk supply to meet an increased need for calories. To do this, they go on a feeding rampage for a few days – eating more often than usual and sometimes acting unsatisfied and fussy after feedings. During a growth spurt it’s common to question your supply. After a growth spurt you’ll find that you have more milk than ever!

“I can’t pump very much.” Pumping output is usually not a good measure of milk supply. Why? Because your body doesn’t always make milk for the pump (it has to be tricked into believing that the pump is your baby!) and when it does the pump doesn’t remove milk as well as your baby does. So don’t gauge your milk supply based on your pumping output. You almost always have more than you pump.

“My baby is fussy when she nurses.” There are many causes of fussiness at the breast. And while hunger is one of them, your baby may be fussy because of gas, pooping, a flow that is too fast or too slow, or a host of other reasons. If you believe that your baby is fussy because he or she isn’t getting enough milk, or if the fussiness is causing you distress, consult a lactation consultant or other breastfeeding support person.

“My baby is suddenly waking up at night a lot.” Night waking can be due to hunger, but it can also be due to teething or “reverse cycling,” (when babies eat less during the day and more at night, often due to a change in routine like a return to work, or distracted behavior during the day).

 

Here’s how to tell if your milk supply is actually low:

1) Your baby’s weight. The best measure of whether your baby is getting enough milk is his or her weight gain.

If you are concerned about your milk supply, have your baby weighed and re-weighed using a baby scale. Scales will always be a little different, so be sure to compare only weights taken on the same scale. Except in critical situations, weight checks every few days or weekly is generally sufficient.

In the first three months of life babies gain an average of 1 ounce per day. That slows to at least approximately a half an ounce per day between 4 and 6 months. 

Occasionally your health care provider may suggest a “test weight,” in which your baby is weighed on a sensitive scale before and after a feeding (with the same clothes on) to determine how much milk the baby received at that feeding. This can give you a snapshot of a feeding, but be cautious in drawing conclusions from the data. The amount of milk babies take in at different feedings can vary widely, so bear this in mind if you do a test weight of your baby.

 

2) Diaper output. You can get a sense of how much your baby is taking in by what comes out. After the first few days, babies generally have at least three poops that are bigger than a quarter in size each day. This frequency may decline after several weeks. And your baby should have five very wet diapers per day. It can be difficult to measure output in very absorbent diapers, which is why your baby’s weight is considered the ‘bottom line.’

 

3) Swallowing. You may also take comfort in how much your baby is swallowing when nursing. This is not a definitive measure of your supply and should be confirmed with information about your baby’s growth, but a period of rapid swallowing (one swallow per one or two sucks) during a feeding shows you that your baby is getting milk. To check out your baby’s swallowing, listen for a ‘cah’ sound or a squeak or gulp, and look for a longer and slower movement of the jaw, often with a brief pause at the widest point. 

 

What to do if your milk supply is indeed low:

If your milk supply is low, be sure to get help from a lactation consultant (IBCLC) or other qualified breastfeeding support person. There are many steps you can take to build your milk supply, and these support people will be able to guide you through that process. You can find a lactation consultant by going to www.ilca.org.

 

Resources:

The Breastfeeding Mother’s Guide to Making More Milk. Diana West and Lisa Marasco, McGraw Hill, 2009.

La Leche League, International: www.llli.org

Kellymom: www.kellymom.com

Find a lactation consultant: www.ilca.org

 

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.

This resource page was made possible by Motherlove Herbal Company.

 

Filed Under: Article, Articles from the professional experts, Breastfeeding, Breastfeeding the newborn, Breastfeeding the newborn, Featured, guest posts, Milk Supply, New article, Relational Resource Tagged With: ,

Baby Explains- Normal Newborn Behavior

August 18, 2011 by

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. 

 

Filed Under: Article, Articles from the professional experts, birth, Breastfeeding, Breastfeeding the newborn, breastfeeding twins, Featured, guest posts, Photos, postpartum, Relational Resource Tagged With: , , , , , , , ,

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

August 9, 2011 by

 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.

Filed Under: Article, Articles from the professional experts, Breastfeeding, breasts, Featured, New article, Nipples, Relational Resource Tagged With: , , , , , , , , ,
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