Frequently Asked Questions

I’m pregnant and don’t know much about breastfeeding. Where do I start?! Tips from the Trenches Getting Started with Breastfeeding Rebecca B. Saenz, MD, IBCLC, FABM, LLLL

While you’re still pregnant

• Read all you can about breastfeeding, but be sure you’re reading up-to-date information. There has been an explosion of research on human lactation and breastfeeding in the last 10 years, and many statements that were formerly dogma have been shown to be false!
• “Nipple preparation” is unnecessary!
• It helps to know ahead of time whether you have inverted or retroverted/retracted nipples. Inverted nipples have probably been noticed by your OB. Retroverted/retracted nipples are the ones that retract inward when you gently squeeze your areola about an inch behind the nipple. In either case, you can absolutely still breastfeed, but you may need extra help.

About nursing bras

• Don’t get fitted for nursing bras until you’re about 35-36 weeks pregnant. Most breast changes that prepare you to breastfeed happen after 32 weeks.
• Get bras that are stretchy to accommodate your ever-changing cup size.
• Avoid underwires – they can press on ducts and cause plugs that lead to mastitis.
• The band should fit comfortably when fastened in one of the middle hooks; that way you can adjust larger or smaller as needed.
• There should not be any “overflow” of breast tissue from the cups.

The First Feeding

• Your baby should be placed on your abdomen/chest – skin-to-skin—immediately after birth. A blanket over both of you will keep him warm. Childbirth triggers increased blood flow to your skin for just this purpose!
• Ideally, the first feeding should be within the first hour of birth and before your baby gets eye drops, the vitamin K shot, or any other procedures.
• But, if that’s not possible for medical reasons, don’t despair!
• If you’ve had an unmedicated, normal vaginal birth, and your baby is immediately placed skin-to-skin on your chest, he can probably latch on all by himself with very little help from anyone. Newborns have several reflexes that enable them to find the nipple by smell (Montgomery’s gland secretions smell like amniotic fluid) and sight (the reason your areola got darker during pregnancy – it makes a nice bulls eye for the baby to aim for).
• If your bra size is anything larger than “AA”, you may need to support your breast, to keep the weight of it from pulling it out of baby’s mouth once he’s latched on.

Holding Your Baby

• He should be facing you, tummy to tummy. If his tummy is actually touching yours, he’ll feel more stabilized and secure and latch on more readily. Be sure he’s curled in around you, not hanging in the air.    
• For babies that don’t have much head control yet, the “cross-cradle” position allows you to support baby’s head and see how his mouth is latching. It also allows you to support his shoulders and buttocks, which makes him feel more secure.
• Keep your hand behind his ears, away from the crown of his head. If the crown of a newborn’s head is touched, it causes a reflex that makes him arch his back and push against your hand. (That reflex making him push against your cervix is how he helped you give birth to him!)
• If you’ve had a C-Section and want to use the football hold to keep baby off your incision, this will support his head well, but you’ll need to lean your own head over to the opposite side to get a good look at how his mouth is opening and latching.
• Be sure baby’s head is tilted slightly back, like sniffing, so his airway and swallowing passages will be in optimal position. It’s hard to swallow if your chin is too close to your chest.

It’s All About the Latch

• Baby needs to latch onto enough of the nipple and areola that the tip of your nipple is all the way to the soft part of the back of his throat. That way, your nipple won’t rub on the roof of his mouth and get sore, and his tongue will be able to get more milk.
• When latching baby on, get him on as far as possible – millimeters count for your comfort!
• Latching on off-center is actually better in most circumstances. If a little areola shows above baby’s upper lip, that’s ok.
• If you touch the part of your areola under the nipple to baby’s bottom lip first, he’ll open his mouth wider. If your nipple is resting just below his nose when you do this, it’ll roll into his mouth in the right spot when he opens!
• Be sure both lips are flanged out like a fish. This prevents his lips from rubbing the sides of your nipple and gets him latched on farther.
• Be sure his tongue is down, and your nipple is going on top of it. He can’t get milk if your nipple is under his tongue (although that may be fairly comfortable for you.)
• If he habitually sucks his own tongue or raises it all the way to the roof of his mouth when he cries, try letting him suck on your (clean) finger for a few seconds before latching. That often gets his tongue down where it belongs.
• You may be able to see the edge of his tongue in the corner of his mouth if he’s latched on well.

When to Get Help​

• If your nipple seems to be going in and out of his mouth with every suck, get a lactation consultant to watch him nurse for a few minutes to be sure things are ok.
  
• If you hear clicks but not swallows, ask for a consult. (It may be normal not to hear very many swallows of colostrum.)
• If it hurts badly, get help. Slight tenderness may be normal for the first 3-4 days in first-time moms. Babies have to suck harder to get colostrum. If it’s still getting worse by day 5 (after milk has “come in”), something’s wrong.
• If it’s still getting worse by day 7, there may be an infection starting.

Swollen breasts

• Some moms experience engorgement when the colostrum becomes milk and increases in volume.
• Not all moms get engorged, particularly if the baby is feeding really well, and you’re hearing lots of swallows.
• If your milk glands do swell up with milk, getting them emptied out at least every 2-3 hours is what determines your milk supply.
• If your baby can’t latch for some reason, you’ll need to pump.
• If you got a lot of IV fluids, you may have swelling between the glands, which can make it hard for the baby to latch on and hard for milk to come out when you pump. Ice packs may help. One clue that swelling is between the glands is that your ankles will be swollen, too.
• If your breasts swell up so much you can make a thumbprint when you press in, and/or the baby can’t latch, try “Reverse Pressure Softening” – press in with your fingers at the spots where you want the baby’s gums to be when he latches – press in enough to make fingerprints. His gums will go into the prints, and he’ll automatically be latched in the right spot!
• If you still can’t get the milk out, see a lactation consultant or breastfeeding medicine specialist for evaluation and other ideas. Sometimes 1-2 doses of a fluid pill can help.

The “Let-Down”, or Milk Ejection Reflex (MER)

• Has nothing to do with feeling let down, sad, or depressed.
• May actually feel exhilarating or empowering!
• Fully half (50%) of moms never “feel” any physical sensation that they can label as a “let-down”. Ever.
• You may not feel an MER while it’s still colostrum. Colostrum is made in smaller quantities and is thicker and flows slower.42. You can know you’re having MERs, even if you don’t feel them, by watching your baby’s sucking pattern. When he begins to swallow regularly, you’ve had one.
• Most moms have 4-5 MERs per side per feeding. You’ll probably only feel the first one, though.
• In the early days, if may take several minutes to get an MER, but they come faster the more the baby feeds.
• Milk flow actually stops between MERs. Some babies will think they’ve gotten all the milk and stop feeding.
• Breast compression will cause another MER and get baby suckling and swallowing again, so he gets more milk. Squeeze your breast back behind the areola to move the milk forward.
• It’s normal to have MERs between feedings, when you see or hear a baby (any baby), or think about your baby. Some moms also have them when they eat. Many moms have them during sex. (Yes, you will want to have sex again eventually.)

A Word About Timing

• DON’T.
• How long it takes a baby to feed depends on many things: mom’s milk synthesis rate, milk storage capacity of mom’s breasts, how long it takes for the MER (see #36 above), how large the baby’s mouth is, how vigorously the baby sucks, etc. There are simply too many variables to be able to figure out a “time” it will take baby to finish.
• Babies may feed for different amounts of time at different feedings, just like adults do.
• How often a baby needs to feed depends on many things: mom’s milk synthesis rate, milk storage capacity of mom’s breasts, how vigorously the baby sucks, how completely mom got emptied out at the last feeding / how much milk baby got at that particular feeding, etc. There are simply too many variables to be able to figure out a “time” it will take baby to get hungry again.
• Babies may go different amounts of time between feedings just like adults do.
• There are exceptions to the above statements: babies who are jaundiced may sleep through their own hunger pangs, due to the sedative nature of the bilirubin. They should be awakened to feed very frequently – every 2 hours or so. Feeding and pooping is what gets the bilirubin out and makes the jaundice go away.
• Exception number two: babies who aren’t feeding well for any other reason may be too weak to give hunger cues. The more chances a baby has to feed, the more feeds will be “good” ones, and the less risk there will be of inadequate feeding. When in doubt, call for help!
• It is OK to wake a baby to feed “early” for mom’s convenience, but don’t make him wait late. Babies will often feed well “earlier” than when they start giving hunger cues, but if made to wait until they’re franticly ravenous, babies will be too upset to feed well.

And Speaking Of Hunger Cues

• Healthy, full-term babies will tell us when they’re hungry, if we learn their language.
• Signals of hunger include rooting, suckling motions with mouth, sucking fingers or fist, etc.
• If asleep, a baby who is about to wake up hungry will often have eyelid flutters or eye movements under the lids, make stirring motions, or sucking noises with his mouth.
• Crying is a late sign of hunger, and may signal that baby is beyond being able to organize himself to latch. A crying baby should be calmed by rocking with him in an upright position on your chest until he settles.
• Babies do have feeding frenzy days, when it seems like you just can’t fill up their “hollow leg”. This is normal, and doesn’t mean your milk is drying up, as long as baby is still wetting enough diapers. It does mean your baby is growing well on your milk! Keep feeding when he’s hungry – he’ll reward you with a smile!

You’ll Know Baby is Getting Enough Milk Because

• For the first week, he’ll wet at least as many diapers per day as his age in days. (E.g. 1 wet diaper on 1st day, 2 on 2nd day, etc.) After 6th day, he’ll continue wetting 6-8 diapers/day.
  
• He’ll pass at least 2 Tbsp. poop per day. This can be divided up however the baby wants, e.g. 1 large or 6 small.
  
• After he’s a month old, this may change to one large poop every 2-3 days. As long as he’s still wetting at least 6-8 times/day, don’t worry.
  
• His poop will turn green by day 3, and yellow by day 4-5, though this change may be slower in jaundiced babies.
  
• He’ll be fairly content after feeds but awaken spontaneously about 2-3 hours later.

Early Weight Gain Patterns

• It’s normal to lose up to 7-10% of birth weight in the first 4-5 days. If you had a lot of fluid retention or IV fluids during labor, he may lose more. Since this is a percentage, bigger babies are allowed to lose more ounces.
• Day 5 is probably the day of his lowest weight. If he’s still losing after that, there’s a problem. If he starts gaining sooner, that’s great!
• When you count weight gain, count from his lowest weight, not necessarily his birth weight.
• In the early weeks, expect baby to gain 4-7oz/week. However, if he’s consistently at the 4oz/week end of that range, get help.
• Breastfeeding babies DO NOT gain at the same rate as formula-feeding babies, and this is a good thing. (Formula feeding is a risk factor for obesity, starting in infancy.) Breastfeeding babies should be plotted on growth curves that were derived from data on breastfeeding babies! (Not the ones printed by formula companies.)

Breastfeeding Culture

• Breastfeeding is the NORMAL way to feed babies since Adam and Eve.
• All other ways to feed and breastmilk substitutes (formula) try to measure themselves against breastfeeding. They don’t measure up because breastmilk is the gold standard.
• Breastfeeding doesn’t have “benefits.” NOT breastfeeding has RISKS. The less you breastfeed, the more risk your baby takes.
• Although exclusive breastfeeding for the first six months is the recommendation, ANY breastmilk is way better than no breastmilk.
• Determination to find a way to make it work is the key.
• Do what it takes to make it work for you and your family. Nothing is written in stone.
• “When bad things happened, we just calmly laid out all the options, and failure was not one of them.” Jerry Bostick, Flight Dynamics Officer, Apollo 13

Other Resources

​La Leche League International, founded 50 years ago as a mother-to-mother support group for breastfeeding mothers, has accredited leaders in 59 countries. Many communities have local groups. To find a group near you, or to ask a breastfeeding question, call 1-877-4LA LECHE (1-877-452-5324).

Books

The Womanly Art of Breastfeeding, published by La Leche League International, and updated every 5 years, is one of the best general books on breastfeeding.

Breastfeeding Made Simple, by Nancy Mohrbacher and Kathleen Kendall-Tackett

Dr. Mom’s Guide to Breastfeeding, by Marianne Neifert, MD

Dr. Jack Newman’s Guide to Breastfeeding, by Jack Newman, MD and Teresa Pitman

So That’s What They’re For! By Janet Tamaro

Websites

www.breastfeedingmadesimple.com – has an animated latch video showing the off-center latching technique described in #20-21; also has a video showing the position of mom’s nipple and areola inside baby’s mouth when he’s latched on properly

http://breastcrawl.org/video.htm -- shows a baby latching on by himself after an unmedicated birth

http://www.asklenore.com/breastfeeding/additional_reading/movies.html -- is the index page for several videos by Dr. Jack Newman, showing latch, what swallowing and good milk transfer look like, and breast compression.

https://www.askdrsears.com/html/2/T020100.asp -- has lots of breastfeeding tips from one of the foremost pediatricians in the US

www.llli.org – La Leche League’s website – has a link to submit questions by e-mail, as well as a site search for info on hundreds of topics
​
What can I expect the first week? Link to http://www.cdph.ca.gov/programs/wicworks/Documents/BF/WIC-BF-Info-WhatToExpectInTheFirstWeekOfBF.pdf

How many times do most babies wake up at night?

0-8 weeks: 3-4 times

2 months: 2-3 times

4 months: 1-2 times

6 months: 0-1 time
​
Waking up is healthy and normal for babies. They need to wake often to breastfeed and waking also helps their brains to develop.

Does breastfeeding hurt?

​It should not hurt but your nipples may be tender, just like your muscles are when you start a new exercise program. If breastfeeding hurts, ask for help.

Can I breastfeed after a C-section? Breastfeeding after a Cesarean Section- Rebecca B. Saenz, MD, IBCLC, FABM

​The surgery itself:

• A Cesarean Section is MAJOR ABDOMINAL SURGERY. There are risks. It can save a baby’s and a mother’s life, but shouldn’t be scheduled just for convenience.
• Often, you’ll be awake with a spinal anesthetic for at least the first part so you can see your baby right after it’s born.
• Ask your partner to sit next to you and hold your hand, just as though you were giving birth vaginally. This is a special event for him, too.

During surgery:

• You may feel tugging, but shouldn’t feel pain.
• You may feel light-headed, or even faint, after they get the baby out.
• Ask whether you can touch, hold, and feed him immediately. Creative circulating nurses can help you to do this “above the screen” while the OB is finishing your surgery if baby doesn’t require any resuscitation.

Immediately post-op:

• It’s OK to feed baby as soon as you’re awake enough to hold him. The anesthetic medications used for C-sections are very short-acting and are out of your system quickly.
• You may feel cold and chilled to the point of being shaky immediately after surgery. This is a normal reaction to both the spinal anesthetic and the massive amount of cold IV fluids you were just given. Ask for blankets. Ask your partner for a hug and help with holding the baby.
• Go ahead, if possible, and feed baby before that spinal wears off. You may need help with positioning, but getting in a good feeding while baby is still fairly alert is important for him and will still be comfortable for you.

About the pain medications:

• The pain meds you’re given don’t come through into breast milk in significant quantities. Even smaller amounts get into colostrum.
• Hopefully, by the time your milk increases in quantity, you won’t need as much narcotic.
• Narcotics can make baby sleepy.
• You can minimize how much narcotic you need by taking the non-narcotic pain meds (“cramping meds”) every 8 hours, whether you seem to need them or not, for the first week or so.
• Minimizing narcotic use will also reduce your likelihood of constipation, which is a whole ‘nother kind of pain . . .
• Get up and walking as soon as you’re awake! The more you move, the less sore you’ll be, and the less constipated you’ll be. Just don’t overdo it – it’s not a footrace.

Positioning the baby for your comfort:

• The first few times you nurse, you may want to try the clutch or football hold, to avoid baby kicking your incision. You will need to lean your own head way over to the side to see whether baby is latched on well, though.
• Another trick is to put a thick pillow in your lap to help support baby’s weight and to be a bumper pad for his kicks.
• Cross-cradle hold often helps you control his head better. Keep his body tucked all the way around you – his full front touching yours – this helps him know to suck!
• Avoid touching the crown of baby’s head. Even though he was born by C-section, he still has that reflex of arching his back when something touches the crown of his head.

Bonding:

• As soon as you’re up to it, begin “kangaroo care” – hold baby skin-to-skin on your chest as much as possible. He should be wearing only a diaper. If it’s chilly, pull a blanket around both of you.
• Lots of skin-to-skin time will help stabilize his heartbeat and breathing and give him a chance to smell you and you the chance to smell him. This can help make up for the separation that often happens in the first few hours after a C-section.

When you get home:

• Remember that you just had MAJOR ABDOMINAL SURGERY! Stay in your jammies and robe for a few days and let other people wait on you. Now is NOT the time to host parties.
• In addition to major surgery, you’re also recovering from childbirth, even if you weren’t in labor. Your body is still getting used to not being pregnant – with all the hormone swings, hot flashes, uterine cramping, etc. that you would have had with a vaginal birth.
• Do what you feel like doing, but don’t overdo!
• Get help with breastfeeding, if you need it.
• Depending on whether your C-section was preceded by a long labor or you had other complications, you may have received more IV fluid than average. You’ll know because your ankles will be more swollen now than they were before the surgery. This can also impact how well baby latches on, which then impacts most other aspects of breastfeeding.
• If your baby can’t latch well because of all the swelling, you may need a diuretic (fluid pill) to help get rid of some of that extra fluid. Drinking lots of water with lemon juice can help, too. See Tips From the Trenches on Engorgement and Edema.
• If your nipples get cracked because baby can’t latch well, they could get infected. Don’t panic, this can be treated without stopping breastfeeding. Do see a Breastfeeding Medicine specialist ASAP for an evaluation.
• If you got a dose of antibiotic during your surgery, be on the lookout for signs of thrush in baby’s mouth or on your nipples. Prompt treatment can keep breastfeeding from becoming too painful. See Tips From the Trenches on Candida.
• It’s not unusual to feel abdominal twinges with certain movements for several weeks after surgery. There WILL be a day when you suddenly realize that normal activity no longer hurts though!

Baby Blues:

• C-sections are a risk factor for Baby Blues, even if you’ve never had them before.
• Some moms feel that their body has failed them by not delivering vaginally.
• Some moms feel that they have failed their baby by not having a normal pregnancy or whatever complication of labor and delivery that resulted in the C-section.
• If your C-section was an emergency to save either your or baby’s life (or both!), you may even experience some symptoms of post-traumatic stress disorder. It was pretty traumatic and stressful, after all!
• Whatever your feelings about your birth experience, it helps to talk to someone who understands. The International Cesarean Awareness Network (ICAN) is a mom-to-mom support group for moms who’ve had a C-section. It has chapters in many cities, with trained leaders that will listen and help you work through those feelings. http://ican-online.org/ or
• If your Baby Blues progress to post-partum depression, you may need to seek professional help. Post-partum depression can be treated without stopping breastfeeding!

Resources:

Wiessinger D, West D, and Pitman T. (La Leche League International.) The Womanly Art of Breastfeeding. 8th ed. New York: Ballantine Books, 2010.

Does breastfeeding cause postpartum depression? Tips From the Trenches #22 – Postpartum Mood Disturbances and Breastfeeding – Rebecca B. Saenz, MD, IBCLC, FABM

Definitions

• Baby Blues- that “moodiness” that nearly every new mom feels in the first couple of weeks after birth.
  • Believed to be due to hormone fluctuations and being overwhelmed with new motherhood.
  • Having a good social support network (i.e., lots of friends and family to help out) lessens the severity and duration of Baby Blues.
  • Having realistic expectations of what new motherhood is really like in the early weeks also lessens the severity.
• Postpartum Depression- a more severe form of postpartum mood disturbance that lasts longer and interferes with mom’s ability to care for herself and baby.
  • Maternal risk factors include previous history of depression, labor complications, a birth that didn’t go as planned, an unscheduled C-section, and mother-baby separation for any reason in the first 24 hours (even “hospital routine”).
  • Infant risk factors for mom’s postpartum depression include delivery complications, baby needing resuscitation or medical attention, mother-baby separation for any reason in the first 24 hours (including “hospital routine”), and infants with congenital defects.
• Postpartum Psychosis- - rare but severe form of mental illness in which mother loses touch with reality, has hallucinations, and may become a danger to herself and others. Often requires hospitalization.

Symptoms-

• 1. Fairly Normal “Baby Blues”: sad, weepy, guilty, isolated, angry, resentful, exhausted, anxious, tense. These are due to a combination of going through a major life change, realizing that reality is different from your previous expectations, hormonal swings, and sleep deprivation. Usually self-limited to the first 2-3 weeks.
• 2. Less Normal (lasting longer than 2 weeks) – Postpartum Depression: ashamed, “not yourself”, overwhelmed, drained, excessive crying, lonely, helpless, mood swings, full of doubts, appetite changes, physical symptoms. These should be evaluated soon by a professional knowledgeable in the treatment of postpartum depression.
• 3. More Serious – Postpartum Depression: Hopelessness, worthlessness, low self-esteem, oversensitive, distracted, confused, extremely agitated, panic attacks, inability to laugh. These should be evaluated soon by a medical professional familiar with the treatment of postpartum depression in breastfeeding mothers.
• 4. Very Serious – Postpartum Psychosis: loss of control, loss of confidence, thoughts of hurting yourself, thoughts of hurting your baby, scary fantasies, hallucinations. These should be evaluated immediately. Go to the nearest Emergency Room.

How Breastfeeding Affects Postpartum Depression

• Although many studies show that babies of mothers with Postpartum Depression may be slower to achieve developmental milestones, the studies which looked at method of feeding show something interesting: breastfeeding babies of depressed mothers did NOT show developmental delay!
• The holding and skin-to-skin contact required for breastfeeding also contribute to bonding with the baby, and to hormonal changes (increasing prolactin and oxytocin) which are favorable for helping mom’s mood.
• Another recent study showed that NOT breastfeeding may be a direct risk factor for postpartum depression. When a mother does not breastfeed and her breasts fill with milk but don’t get emptied, it’s as though her body thinks she’s had a stillbirth. Her other hormones and body systems, including brain hormones, react by grieving.
• If baby isn’t breastfeeding well for any reason, Mom can feel like her body is failing her, perhaps “again” if she’s had a bad pregnancy or birth experience, or that the baby is rejecting her.
• Since breastfeeding problems can contribute to Baby Blues, it’s important to get help sooner rather than later!
• Breastfeeding most definitely does NOT cause postpartum depression!
• Moms who had unrealistic expectations about breastfeeding (e.g. that baby would only feed every 3 hours) or babies in general (e.g. that a newborn sleeps all night at a young age) are more likely to think they’re “doing something wrong” and get depressed.

How Postpartum Depression Affects Breastfeeding

• Mom may feel like she doesn’t want to breastfeed as often as is necessary to establish good milk production.
• She may feel “tied down” or “antsy” while she is breastfeeding.
• She may not realize what “normal” is for breastfeeding moms and babies, especially if she doesn’t have good support from other moms who’ve breastfed.
• Depressed moms often lose their perspective and blame breastfeeding for their depressed mood and other things that aren’t going well – sleep deprivation, fussy baby, etc., not realizing that mothers who aren’t breastfeeding will also be sleep deprived, and are actually MORE likely to have fussy babies.
• The depression may make mom feel sleepy or react worse to the sleep deprivation of new motherhood.
• Depressed mothers often forget to eat, due to lack of appetite, which then leads to unstable blood sugar levels, which make depression worse. Unstable blood sugar levels may affect milk production.

Treatment for Baby Blues and Postpartum Depression while Breastfeeding

• Diet – see also “Depression Diet” under Notes tab on Facebook Page
  • Increase complex and whole-grain carbs
  • Reduce simple sugars to maintain stable blood glucose
  • Increase levels of iron, zinc, selenium, folic acid, and B-vitamins
  • Eliminate phenylalanine (NutraSweet, Equal)
  • Increase proteins, especially those containing high tyrosine (greens, beans, spinach) and tryptophan (turkey, salmon)levels
  • Maintain good hydration status
  • Avoid caffeine, alcohol, and tobacco
• Dietary supplements: should not be used without consultation with a medical or nutrition professional. There are several that may be helpful in correct doses.
  • Get your Vitamin D level checked! There is some evidence that Vitamin D deficiency, which is much more common than most people realize, may contribute to depression.
• Bright Light Therapy – especially useful in northern latitudes with short days in winter and long winters
• Cognitive-Behavioral Therapy –
  • Relaxation techniques for management of crisis situations.
  • Realistic expectations of sleep patterns of newborn and practices to maximize her REM sleep, by synchronizing her sleep pattern with baby’s; proximity of sleeping arrangement and safe co-sleeping practices.
  • Importance of self-talk - identifying negative patterns and changing to positive reinforcement.
  • Therapeutic journaling
  • Spiritual aspect - prayer/meditation as means to inner peace.
  • Pharmacologic –
    • The most commonly used class of antidepressants is the SSRIs – Selective Serotonin Reuptake Inhibitors.
    • Most of these are safe for use in breastfeeding mothers, but some are safer than others.
    • Consultation with a physician knowledgeable in lactation pharmacology is a good idea.
    • Alternatively, you may ask your physician to call the Infant Risk Center at Texas Tech at 806-352-2519. It is staffed M-F 9-5 CST with lactation pharmacologists that are happy to assist physicians or answer questions from breastfeeding mothers.
• “Alternative” Treatments –
  • Aromatherapy:
    • Lavender-based scents for relaxation
    • Citrus-based scents for invigoration
    • Fennel and Jasmine to increase milk supply
  • Homeopathic: these are safe in breastfeeding--
    • Ignatia amara - during periods of feeling extremely overwhelmed or sad
    • Pulsatilla - if feeling overwhelmed and suffocated
    • Bach’s Rescue Remedy - during periods of feeling anxious (do not combine with others)
  • Herbal: These should only be used with guidance from a knowledgeable professional!
    • Blessed Thistle tea one to two cups per day
    • Chamomile (preferably German, as Roman can be allergenic for those with hayfever) tea. As needed for relaxation – for occasional use
    • Lemon balm tea for mental clarity and relaxation; also has mild galactogogue effect
    • Oatmeal for insomnia
    • Others, with guidance from a knowledgeable professional
  • Exercise Therapy -
    • Aerobic exercise increases levels of endogenous endorphins – the “feel good” neurotransmitters.
    • Music therapy – whatever you enjoy for relaxation or getting energized. May be combined with exercise!

Support:

Community resources for social support: meal preparation, childcare for older children, housework/housecleaning services.
​
La Leche League International www.llli.org for breastfeeding support.

Resources:

Kathleen Kendall-Tackett. PhD, IBCLC. Hidden Feelings of Motherhood. 2001. New Harbinger Press.
​
http://www.breastfeedingmadesimple.com/Depression.html

http://www.scienceandsensibility.org/?tag=postpartum-depression

http://www.suite101.com/content/ways-to-treat-postnatal-depression-a53840

Do I need to eat a special diet to breastfeed? Tips from the Trenches #11– What to Eat or Not to Eat While Breastfeeding Rebecca B. Saenz, MD, IBCLC, FABM

What to Eat--

• Protein, complex carbohydrates, and healthy fats. A good, basic, healthy diet is best for you and baby while you’re still “eating for two.”
• Yes, you can be vegetarian, even vegan, and make high quality and adequate quantity of milk to breastfeed. Vegetarians do need to pay particular attention to vitamin B-12 intake, and to getting complete proteins.
• Eat to hunger. You do NOT need to eat “an extra XXX (specific number) of calories per day.” If you pay attention to your body, your own hunger signals will guide you, just as your baby’s do.
• Part of your pregnancy weight gain was the storing up of energy / nutrients / and water your body needs to make high quality colostrum and milk in those early days when you’re recuperating from childbirth and don’t feel like eating.
• If you’ve had a C-section, you may need to eat extra protein, since your body is healing from major surgery AND feeding a baby.
• Extra vitamin C is good to help with tissue repair after a surgical birth, as well.
• Garlic is ok, and babies even like it. There’s an actual study on this one!
• There are foods that help prevent postpartum depression. See the “YES / NO” diet posted on our Facebook page as a note.
• There’s a widely held belief that oatmeal increases milk supply. This has never been proven, but it’s also never been disproved. Since it’s healthy anyway, if you like it, go ahead!

What NOT to Eat--

Hmm. Well . . . Barring extenuating circumstances, this is a pretty short list . . .

• Sage (a common Thanksgiving seasoning – turkey and dressing) can decrease milk supply.
• So can parsley, rosemary, and thyme, in large amounts.
• Strong mint oils (peppermint, spearmint, etc.) – like in “Altoids”
• If there’s any family history of “atopic diseases” such as allergies, hayfever, eczema, or asthma, or if there’s a family history of milk allergy, you might want to avoid dairy and dairy products. That’s a whole ‘nother Tips – see “Dairy Intolerance and Allergies”
• No, you DO NOT have to “drink milk to make milk”. Cows don’t drink milk beyond infancy.
• You also don’t have to “force fluids” (unless you have the flu) – just drink to thirst.
• If there’s a family history of peanut allergy, you might want to avoid peanuts, soy products (including soy-based dairy substitutes), chickpeas, hummus, and things in that family.

Otherwise, eat what you normally eat, within reason.

Binging on particular foods is never a good idea.

Crash dieting or fad diets aren’t a good idea, either, as they are often not balanced. Exclusive breastfeeding burns as many calories per day as an aerobic workout, and you can do it with your feet propped up!

Everything in moderation. Even a little “junk food” is OK once in awhile.
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The reason for eating healthy is so MOM will be healthier. We’ve long known that mom’s breasts will rob mom to put the necessary nutrients in the milk at mom’s expense.

Things that AREN’T on the “Never Eat While Breastfeeding” list:

• Spicy foods. Moms all over the world eat their native cuisines and breastfeed their babies just fine. Italian mothers eat lots of garlic. Mothers in India eat curry. Mothers in Mexico eat jalapenos. And none of their babies complain. The great thing is, amniotic fluid was flavored with whatever mom ate while pregnant; breastmilk will be, too. And that’s what gets baby’s taste buds ready for family mealtime.
• “Gassy” food. Things that cause gas in mom don’t usually cause gas in baby, and mom’s gas isn’t absorbed to pass through the milk into baby. That said, some babies are sensitive to some things, but the leading culprit is often dairy. Broccoli, cabbage, cauliflower, greens, and beans are usually OK.
• Caffeine in moderation. The American Academy of Pediatrics states caffeine is “usually compatible with breastfeeding.” You’ll know you’re overdoing it if baby gets irritable and won’t take naps. Long-term, high-dose use has been shown in one study to “possibly” lower iron content in breastmilk.
• Carbonated soft drinks. The bubbles make mom burp, but don’t cause a problem for baby. These are not the healthiest choices for fluids for mom, however.
• Chocolate. It does contain both dairy and caffeine, but if you’re not otherwise overdoing either of those things, a little is fine.

Dietary Supplements--

• Are prenatal vitamins necessary while breastfeeding? Not necessarily, but if you have doubts about your diet, they’re not a bad idea, either.
• What about fish oil / omega-3-fatty acid / DHA, etc. supplements? Again, not a bad idea if you’re not sure that you’re getting enough in your diet.
• Vitamin D – Experts now recommend 1000IU of vitamin D-3 daily for ALL women. Recent research has indicated that vitamin D is much more important than we thought, and that many women are deficient. Good news: supplementing mom increases vitamin D levels in your milk! Getting some sunshine each day is another way to get vitamin D.
• Calcium – Studies indicate that calcium intake should remain at 1200mg per day while breastfeeding, just as in pregnancy. Your bones begin to retain calcium again about 6 months after birth, whether you’re breastfeeding or not, as long as your intake is adequate.
• DO read the labels of all “Women’s Supplements” carefully. Some contain herbs or herbal blends for “female hormonal support” that may decrease milk supply. Common culprits include Vitex and Black Cohosh.

Cause and Effect--

• If you notice baby gets fussy or has greenish or mucousy stools consistently after a particular food that you eat – this may indicate that baby has a sensitivity to that food.
• Common culprits are milk/dairy products, soy/peanut family, wheat, corn, citrus, strawberries, tomatoes, chocolate, or caffeine.
• Other indicators are a red rash around the anus or a diaper rash.
• Food sensitivities are often outgrown by 6-8 months of age, so avoidance of those foods by mom is temporary.
• If you eat a whole pan of brownies, or the equivalent of any other form of chocolate, baby’s poop may resemble chopped spinach the next day. If baby is not fretful, this is nothing to worry about.
• When baby starts solids, beware of foods with dyes in them. Babies often can’t digest those, and they come out in the diaper. Ex. Blue’s Clues applesauce. This has NOTHING to do with breastfeeding.

Resources--

​The Womanly Art of Breastfeeding, published by La Leche League International
​
Whole Foods for the Whole Family, published by LLLI.

Eat Well, Lose Weight While Breastfeeding, The Complete Nutrition Book for Nursing Mothers, by Eileen Behan, RD.

The Family Nutrition Book, by William Sears, MD and Martha Sears, RN.

Do I need to stop breastfeeding if my baby has jaundice? Tips from the Trenches – Newborn Jaundice and Breastfeeding Rebecca B. Saenz, MD, IBCLC, FABM

Different Kinds of Jaundice:

• “Pathologic” jaundice happens when there’s something wrong with the liver. This can happen in adults or babies, but this handout isn’t about pathological jaundice.
• Babies can also get jaundiced when there is a blood-type mismatch between a mom with type O blood and a baby with type A or B, if the placental barrier between the two has been broken before birth. This handout isn’t about “ABO incompatibility” jaundice, either.
• Normal “newborn jaundice” or “neonatal jaundice” is not unusual in breastfeeding babies.
• Some researchers think that low levels of jaundice in the first few days of life may actually be protective against leukemia and other cancers later

Risk Factors for Jaundice:

• Not being fed soon enough after birth. This is one reason “feeding within an hour” is one of the “10 steps to breastfeeding success”.
• Labor medications that make baby sleepy or uncoordinated. Even an epidural increases risk, because babies often don’t feed effectively soon enough.
• Mom getting a lot of IV fluids in labor – for long labor, induction, epidural or spinal, blood pressure problems, heart rate problems for baby, or any other reason. Lots of IV fluids = problems getting milk/colostrum by baby.
• Bruises from forceps or vacuum-extraction deliveries. Extra blood cells to break down may mean higher bilirubin levels. Baby may also not feed as effectively if he has a headache from the forceps or vacuum bruise, called a cephalohematoma.
• Baby getting cold stress – like when he’s separated from mom instead of being placed skin-to-skin immediately after birth.
• Not feeding often enough or well enough. This is why limiting feedings to a schedule or set number of minutes is a bad idea. Using breast compression to help baby get as much milk as possible from the very first feed may help prevent excessive jaundice.

How Jaundice Happens:

• When a baby is born, his first bowel movements are a sticky black substance called meconium.
• Meconium is formed when bilirubin is broken down and the by-products are secreted into the small intestine for disposal.
• If a baby doesn’t poop soon enough or often enough after birth, some of the bilirubin can get reabsorbed. (This is one reason babies should feed within an hour of birth!) Frequency of poops is a more important measure of effective breastfeeding in the first couple of weeks than number of wets diapers!
• Excess bilirubin in the bloodstream gets deposited into the skin, causing the yellow color we call jaundice.
• The yellow color appears first in the whites of the eyes, then the skin of the face, chest and abdomen, in that order. It disappears in the reverse order.
• Jaundice becomes a problem when the bilirubin levels get too high too fast. Doctors use fancy graphs to determine when the bilirubin level is too high, taking into account the gestational age of the baby, his actual age in hours, and whether it’s still rising or starting to fall.
• Jaundice interferes with breastfeeding because bilirubin acts as a sedative to keep baby sleepy and uncoordinated, like he’s drunk. Jaundiced babies can then get dehydrated easily or not gain weight because they don’t feed effectively or fall asleep before they finish.

Ways to lower Bilirubin:

• Sunlight exposure lowers bilirubin levels. Put baby, naked except for diaper, in a sunny window. If it’s winter, you may need to warm the room to keep baby from getting a chill.
• Bili-blankets, prescribed by doctors and rented from hospitals, wrap around the baby and plug into an electrical outlet. They transmit the kind of light that lowers bilirubin levels around the baby’s midsection. They interfere less with breastfeeding than overhead bili-lights.
• Bili-blankets can be used for “home phototherapy” to keep from having to be re-admitted to the hospital. Use as directed for the full amount of time recommended by the doctor each day.
• Occasionally, readmission to the hospital for more intense phototherapy is necessary. Ask to be able to stay with your baby so you can continue to breastfeed as often as possible. You will probably also have to pump your milk to give to your baby as a supplement, since babies with bilirubin levels high enough to need readmission are usually not feeding effectively directly at the breast.
• Since bilirubin is excreted in baby’s poop, levels will also be reduced as baby stools. More breast milk intake = more stools.
• Breast milk has a laxative effect on the baby’s intestines, so keep giving as much breast milk as possible in whatever way is necessary. Formula causes constipation and slows down the bowel movements. Sugar water does NOT increase bowel movements, so it won’t help.

Feeding While Baby is Jaundiced:

• If baby is alert enough to latch well, feed at breast.
• Use breast compression to keep milk flowing and keep baby swallowing as much as possible. This may even keep him from getting sleepy as quickly.
• If baby is wetting 6 or more diapers /24 hours (“soaked”, not just damp) AND having several stools per day that are larger than a tablespoon in volume, he’s getting enough milk to stay hydrated and lower his bilirubin levels.
• Don’t rely on baby to give feeding cues while he’s jaundiced. Since bilirubin is a sedative, he may sleep through his own hunger pangs. Wake him and offer to feed every 2 hours during the day, and every 3 hours at night.
• If he’s not having enough (or large enough) bowel movements, you will need to pump some extra breast milk to supplement with. Ask a lactation consultant to get you started. You may need to rent a hospital-grade breast pump temporarily to do the most efficient job of collecting milk and protecting/increasing your supply.
• If baby keeps falling asleep before getting enough milk, you’ll need to give your expressed breast milk to him by bottle or syringe or by finger-feeding or other methods. These methods don’t require as much coordination on baby’s part – remember, he feels drunk and uncoordinated, so he’s having a hard time getting his tongue to do the right latch-and-suckle motions.
• It’s also important to pump your milk each time baby doesn’t get you emptied out well, in order to preserve your milk supply.
• Ask your lactation consultant how much to supplement with each feeding and how often to pump.
• The Golden Rule is – The more breast milk in, the more poop out, and the faster the bilirubin falls.
• As bili levels fall, expect stool to turn from black to brownish-green to brownish-yellow to mustardy yellow.
• It’s not unusual for baby’s weight to stay stable or gain very slowly while jaundice is clearing. He’s using most of his calories to metabolize the bilirubin. Once the bili levels are down, he’ll start gaining.
• Rapidly falling bili levels and progression of stool color changes count as progress and signs of sufficient milk intake, along with wets and dirty diapers, even if weight is stable for a few days. (He shouldn’t keep losing weight, though.)
• Keep in mind that whatever extreme measures you have to take to make #32 happen are only temporary – for a few days at most!
  
  

In a few weeks, this will all be a distant memory, because you’ll be a pro at breastfeeding your beautiful baby.

One Last Type of Jaundice:

• If low levels (bili<12) of jaundice persist for more than a week, it may be a type called “breast milk jaundice”.
• Breast milk jaundice happens due to an inheritable trait in how certain proteins in breast milk are metabolized.
• It is NOT harmful, and it can last up to 2 months.
• In breastmilk jaundice, the baby is awake, alert, feeding well, wetting and stooling fine, happy, healthy, and gaining weight well. He’s just a little suntanned-looking.
• You don’t need to “do” anything about breast milk jaundice; it will go away on its own, though slowly.
• You do NOT need to substitute formula for a day to “prove” it’s breast milk jaundice – that would increase baby’s risk for a myriad of other problems for no good reason. If all the conditions in #40 are met, that’s what it is.

I’m confused about vitamin D supplements. Does my baby need one? Tips from the Trenches – Vitamin D and Breastfeeding – Rebecca B. Saenz, MD, IBCLC, FABM

What Vitamin D is

• Vitamin D is actually a hormone – a chemical messenger produced by the body to regulate certain metabolic systems.
• It originally got labeled as a “vitamin” because it’s essential to good health, and because you can absorb some from your diet.

What Vitamin D does, and why it’s important

• Vitamin D regulates a whole list of bodily functions, including calcium absorption and bone-building, insulin production in the pancreas, inflammatory reactions all over the body, and even the immune system.
• Vitamin D deficiency can affect many organ systems even before there are any symptoms.
• Vitamin D deficiency has been linked to diabetes, heart disease, fibromyalgia, multiple sclerosis, Alzheimer’s disease, several types of arthritis, osteoporosis, high blood pressure, high cholesterol levels, psoriasis, depression, and several types of cancer, including breast, colon, and prostate.

Vitamin D levels – to check or not to check?

• The type of vitamin D to measure in human blood is called “25-hydroxy-vitamin D.”
• If you live above the 35th parallel (the line formed by the northern borders of MS, AL, and GA), or have a mostly indoor lifestyle, or have had a particularly cold/wet winter that has prevented your normal amount of sun exposure, you should probably have it checked.
• If you have symptoms such as bone pain, decreased immune responses, or inflammatory reactions, you should probably have it checked.
• If you have kidney or liver problems, you should probably have it checked.
• If you had gestational diabetes, you should probably have it checked.
• If you have had skin grafts, or any condition that decreases absorption of fat-soluble vitamins from dietary sources (Crohn’s Disease, cystic fibrosis, gastric bypass surgery, celiac disease), you should have it checked.
• If you have tuberculosis, sarcoidosis, hyperthyroidism, hyperparathyroidism, or take steroid medicines or anti-seizure, meds, you should have it checked.

​Vitamin D levels in human milk

• Although most nutrient levels in human milk are remarkably stable regardless of maternal status, Vitamin D levels are the exception to this rule.
• Throughout much of human history, mothers spent a fair amount of time outdoors and were able to absorb adequate Vitamin D from sunlight exposure, and thus their milk levels were probably adequate.
• Since the Industrial Revolution, and - in recent years – the association of sunlight exposure with skin cancer, many mothers have drastically decreased their sunlight exposure through sun avoidance and use of sun-block lotions and clothing.
• This change in modern lifestyle has had the effect of lowering both maternal Vitamin D levels, and levels in human breastmilk.
• However, if maternal levels become “sufficient” – in the high-normal (50-60) range - through supplementation, human breastmilk levels will also rise to levels sufficient for your baby.
• Maternal Vitamin D levels –
• Normal levels range from 30-60ng/ml.
• If yours is below 30ng/ml, you should take a daily supplement and have it rechecked in 2-3 months. The dose of supplement ranges from 400IU daily to 2000IU daily depending on your level.
• If yours is below 20ng/ml, you should take a pharmacologic-dose prescription supplement and have it rechecked in 2-3 months.
• Toxicity (too much) isn’t reached until blood levels are higher than 150ng/ml. (As a comparison, lifeguards’ levels at the end of summer in Los Angeles, CA, are typically only 80-90ng/ml.

Sources of Vitamin D

• Sunlight. But remember: A little is good, but more is bad.
• The amount of sun exposure it takes to make you turn the lightest type of “sun-pink” – not even a real sunburn – is enough to cause your skin to manufacture 6000 IU of vitamin D.
• Half that amount of sun exposure will cause 3000 IU of vitamin D absorption. This is enough for several days.
• This amount of sunlight is highly variable, and very individual. This is why we can’t say “X minutes per day” etc.
• It depends on your location in reference to the equator (latitude), season of the year, time of day you’re in the sun, amount of cloud cover and/or air pollution that day.
• It also depends on your own genetics, complexion (fair vs. dark), skin type (burn vs. freckle vs. tan), and amount of skin surface exposed.28. Be sure to apply sunscreen fairly quickly after going outside (10-15 minutes), to prevent skin cancer. SPF15 and above blocks >99% of the UVB wavelength that converts vitamin D in the skin.
• Dietary—whale blubber, seal fat and meat, North Atlantic oily fishes (salmon, mackerel, tuna) are the richest dietary sources of vitamin D. Fortified dairy products, orange juice, and cereals also have some.
• Supplements – come in tablet and capsule form for adults, and drops for infants. Look for the dose in “IU” – International Units. Look for Vitamin D-3 – it’s the most potent.
• Pay close attention to dosing, especially for infant supplements! Use only the dropper that comes with that particular product. Don’t give or take more than standard recommendations, unless specifically prescribed by your physician.

Infant Vitamin D supplementation

Infant Vitamin D supplementation –

• The American Academy of Pediatrics currently recommends that all infants receive 400IU of vitamin D daily beginning within a few days of birth.
• This recommendation is for ALL infants, regardless of how/what they are being fed.
• This supplementation should begin within a few days of birth.
• This recommendation does not address the mother’s needs, however.
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So, the bottom line

Can I breastfeed my premature baby? Tips from the Trenches – Pumping for Preemies – Rebecca B. Saenz, MD, IBCLC, FAB

Getting started

• Colostrum might be easier to hand-express than to pump, because it’s so thick. It’s only made in teaspoonfuls, not ounces.
• Try to start pumping/ hand expressing colostrum as soon as possible – preferably within 6 hours – of giving birth. The sooner you get started, the faster your milk will come in.
• Beg, borrow, or rent a hospital grade pump ASAP for when your milk “comes in” – even the really good high-end personal pumps aren’t designed for round-the-clock use.
• Have the flanges fitted to your nipples – they do come in different sizes. Properly fitted flanges shouldn’t rub and your nipples shouldn’t get stuck. You’ll get more milk because you’ll get emptied out better, and you won’t get sore.
• Don’t press the flanges into your breasts – that can block off the milk ducts. Hold them so that the edges are flat against your skin.
• Ask that your first colostrum be the first feeding your baby gets. This is important for preventing “NEC” – a serious intestinal infection that is 20 times more likely to occur in premature babies that are formula-fed.

While in the hospital

• While you’re in the hospital, keep your pump, parts, collection bottles, labels, a pen to write date & time, lanolin, bra pads, and drinking water on your tray table – and keep it in arm’s reach. That way you won’t have to get out of bed to pump.
• Pump/hand express as often as possible in the first week. The more you do, the faster the transitional milk will come in, and the more you’ll get when it does. Try not to go longer than 3 hours without pumping.
• Visit your baby as much as you feel up to – and pump right when you return to your room. You’ll have better let-downs. Some NICUs even have a pumping room there that you can use.
• Have your partner take pictures of your baby that you can look at while you pump.
• Let the NICU nurses know you’ll be breastfeeding and that you’ll want to hold your baby as soon as he’s medically stable enough. Even “just” holding your baby before he’s ready to start feeding will do wonders for your hormone levels.
• If you’re able to do “kangaroo care’’ – skin-to-skin holding – your baby may nuzzle and lick your nipples and try to latch on! Follow his lead – even if he doesn’t get much milk in these early practice sessions, he’s learning your smell and taste, and this helps your hormone levels, too

Once you’re home

• At home, set up a “pumping station” with the above items (see #7) so everything’s handy.
• For middle-of-the-night pumping, make your nightstand into your pumping station, and add a cooler tote with blue ice to put the milk in until morning.
• MANY things affect how much milk you make. You had no control over developing complications during your pregnancy – blood pressure, gestational diabetes, preterm labor, or how early your baby came, but those things and/or the medicines that treated them can impact how soon your milk comes in and how much you make. The factors that you can control are how often you pump and whether your pump flanges fit. And how often you pump. And how often you pump!
• Keep pumping often, even if you don’t get much milk. It’s not about how much milk you get, it’s more about continuing to tell your breasts to keep making more. And they will if you keep telling them to.
• DO NOT compare how much milk you get to anyone else – too many things are different for every mom and baby.
• Go to visit your baby as much as is practical (see #9 above). The closer he gets to coming home, the more you’ll want to be there.19. DO keep a record of how much milk you get per day. If the 24-hour total starts to drop, ask for help immediately. There are medicines that can help, but they take up to 4 days to have an effect.
• It is normal to get more milk at some pumpings and less at others, and for that to be inconsistent. It’s normal to get more from one side than the other.
• Make pumping a priority – not only are you the only one who can do it – your body knows exactly how far along your pregnancy was and is making milk specific for your baby’s gestational age with antibodies for your family’s home environment.
• Try not to go longer than 3 hours between pumping. One time interval of 4 hours at night is ok if you make up for it during the day. Remember that term newborns feed about every 2 hours, and preemies have even smaller stomachs and will want to feed even more often.
• Have a goal of 8 or more pumping sessions per 24 hours, but don’t obsess about being exactly “on time” for each one.
• Pumping for 100-120 minutes / 24 hours is a good goal, but it’s more important to have more frequent, shorter sessions than a few longer ones.
• It’s ok to stop mid-session for a few minutes to answer the phone, go to the bathroom, tend to an older child, etc. You may even get another/better/extra let-down that way.
• Pump until you’re empty each time – not a specific number of minutes. Getting empty is what tells your pituitary to keep increasing supply. Keep going for a minute or two past the last drops of milk, in case you get one more let-down.
• Use breast compression to help get empty faster – this also increases fat/calorie content of your milk (which is already richer than full-term milk!).
• It’s ok to drink caffeinated beverages again – the amount in 2 cups coffee/ day is AAP approved while breastfeeding – and the tiny amount that comes through into your milk may just help prevent apnea in your baby.
• Before sitting down to pump, go to the bathroom, and be sure you have: all the pump parts, including an extra collection bottle, your cell phone, a healthy snack, and a large glass of ice water.
• In the first couple of weeks, be sure you’ve taken your meds for uterine cramping before pumping if you have a dose due.
• While pumping, close your eyes and think about your sweet baby getting well and growing because of your milk!
• Even though you ARE Supermom for doing all this pumping for your baby, you ARE NOT Wonder Woman. Accept absolutely every offer of meals, help with housework, and invitations for older kids to go play at friends’ houses. If specific offers don’t get made, ask. Write down names and phone numbers of people who say “Call me when things settle down, and I’ll come help/bring food, etc. then. Then call them back – the week the baby comes home – becasue even though you’ll be feeling better, you’ll need to devote your time to your baby, not cooking, laundry, etc. Remember that the people offering to help will be blessed by helping you as much as you will be, and don’t deny them that opportunity!

Getting Baby to Breast

• Ask that breastfeeding (not a bottle) be the first feeding by mouth your baby receives. There is some evidence that this can help prevent nipple confusion.
• Ask the nurse to call the Lactation Consultant to help you get your baby latched on the first time when he’s ready to start feeding at breast.
• Since bright lights make a baby not want to open his eyes, ask for dim or indirect lighting – usually the “breastfeeding room” has this option, and most NICUs have dim lighting around the isolettes.
• Premature babies can concentrate and focus on the breast better if they are “flexed and centered” - held in a position with legs flexed at hips and knees, and arms flexed at elbows with hands together in the midline. Many NICU nurses know this and will swaddle them in this position for you.
• Once baby is latched on and takes a few suckles, you can use breast compression whenever he pauses to get him going again.

After Baby is Home, too!

• Realize that getting a premature baby to feed at the breast is a transitional process, not a singular event. Progress often comes in a “3 steps forward, 2 steps back” pattern. It’s a learning process for both him and you, but it IS SO WORTH IT to persevere, even though the process may take several weeks.
• You’ll need to keep up your pumping routine, and give “top-ups” of your pumped milk until baby is fully at breast to keep your supply up and to keep baby gaining weight appropriately. Babies learning to breastfeed early aren’t very good at getting you emptied out. They are great at snuggling and looking sweet, though.
• Continue doing Kangaroo Care at home as much as possible – you have lots of bonding to do – and the more opportunities baby has to be near the breast, the more he’ll want to give it a try.
• As baby gets more milk at breast, you won’t have to pump as much! Sometime around when you would have been 36 weeks pregnant, baby will start nursing MUCH better – hang in there!

Breast Care

• If it hurts to pump after your milk is in, something’s wrong – get help!
• Several times daily – after pumping – check your breasts for knots / lumps / plugs. You may need to massage those areas during pumping / feeding.
• If a lump / plug persists, (and you’re not allergic to peanuts or soybeans) try taking Lecithin (Soy Lecithin) 1200mg (check the strength and do the math) 4 times daily. You’ll find this in the “dietary supplements” section of your grocery or drug store, and yes, it’s safe while breastfeeding.
• If you get fever and flu-like symptoms and have a sore, red area of one breast, call your doctor. This is mastitis and needs to be treated immediately with antibiotics. Be sure to mention that you’re breastfeeding / pumping so you’ll get antibiotics that are safe.
• If you or your baby has gotten antibiotics for any reason (ruptured membranes, group B strep, C/Section, etc.) look for white spots in your baby’s mouth periodically. This is oral thrush, which is contagious to you when baby goes to breast. If your nipples start to have burning pain and are getting pink or you get cracks at the bases of the nipples, this could be nipple thrush, and needs to be treated to keep from getting worse. Ask the lactation consultant whom to call.

Old Wives’ Tales that have a grain of truth

• “Premature babies sleep until their due date.” Premature babies are sleepier and do have to be awakened to feed. Their feeding cues (when they start to give them) are much more subtle. Sometime around their due date, they do begin to wake up more and feed better.
• “You can’t fit a size XL nipple into a size S mouth.” True, but you’d be surprised how wide a preemie can open his mouth when there’s dinner involved! If there’s still a mismatch, you may need to keep pumping for a little while longer. His mouth will grow; your nipples won’t.
• “You can’t spoil a newborn.” True. Enough said.

And one that doesn’t

• ​“Never wake a sleeping baby.” Babies sleep for a lot of reasons, including that they are neurologically immature. Preemies, especially, may sleep through their own hunger pangs and not get enough to eat if you wait for them to wake up. As they get close to their due date and have been growing well for awhile, they begin to wake on their own!

Resources

​Nyqvist, KH. Breastfeeding Preterm Infants. Chapter 7 in Supporting Sucking Skills in Breastfeeding Infants, edited by Catherine Watson Genna. Sudbury, MA: Jones and Bartlett, 2008.
​
Lang, Sandra. Breastfeeding Special Care Babies. 2nd ed. London: Elsevier Health Sciences, 2002.

Gotsch, Gwen. Breastfeeding Your Premature Baby. Schaumburg, IL: La Leche League International, 1999.

How can I increase my milk supply? Tips from the Trenches – Increasing Milk Supply– Rebecca B. Saenz, MD, IBCLC, FABM

How your breasts make milk— or not (They aren’t just faucets)

• Prolactin is a hormone secreted by the pituitary gland at the base of your brain. It travels through your bloodstream to the prolactin receptors in your breasts.
• When prolactin attaches to a prolactin receptor, it tells that section of milk gland to begin making milk.
• In the first few weeks after birth, prolactin receptors are facilitated by frequent (every 2-3 hours) emptying of breast glands. If frequent emptying does not occur, some of the prolactin receptors may not become responsive to prolactin. This is why the first few weeks are critical to establishing a good milk supply.
• Prolactin rises during pregnancy, but is inhibited by progesterone. This is why you have colostrum in the first few days, and it changes to milk after the progesterone levels that were high during pregnancy have fallen, which takes a few days. This is why even progesterone-only birth control can affect milk supply.
• Prolactin receptors are turned “off” temporarily by another hormone, present in the milk itself, called Feedback Inhibitor of Lactation, or sometimes called Prolactin Inhibitory Factor. When breasts get full of milk, this hormone attaches to prolactin receptors to tell the glands to quit making milk. This is why going too long between feedings or pumping sessions can decrease milk supply. Feeding or pumping pulls the FIL off of the prolactin receptors so you’ll start making milk again.
• So, to establish a good milk supply, you have to get your breast glands emptied out early and often. And, to keep it up, you have to keep emptying out well and often. Empty breasts make milk faster than full breasts.

INCREASING milk supply

• Any change in routine that increases how often or how completely your breasts are emptied out will increase your milk supply, BUT, it can take a few days for your breasts to get that message from your pituitary gland, where prolactin is made.
  • Baby latching better and suckling more vigorously.
  • Breastfeeding or pumping more often.
  • Using breast compression to get emptied out better
  • Getting properly-fitted pump flanges
  • Upgrading your pump. Better pumps get you emptied out better, because they’re faster and have a better suction/relaxation ratio. Double pumping will also help.
  • Baby’s growth spurt, which causes more frequent feeding AND better emptying.

DECREASING milk supply

• Any change in routine that causes some milk to stay in your breasts will send the message that too much milk was made, and cause a decrease in supply.
  • Baby not latching well, so not getting as much milk as he could/should. Be sure baby is getting the best latch possible!
  • Scheduled feedings, instead of feeding when baby is hungry. Baby won’t feed as well at some feedings, which will leave some milk in the breasts for too long. Babies can’t be expected to tell time anyway.
  • Sleepy baby, whether from labor medications, jaundice, or illness. If baby is sleepy, you should wake him to feed about every 2 hours, to make sure he’s getting enough to eat, because he’ll likely not be feeding as vigorously as if he weren’t sleepy.
  • Engorgement between the glands, from a lot of IV fluids during labor, can keep the milk from being able to get out, even when you are feeding or pumping often enough. (If your ankles are swollen, ask your doctor for 1-2 doses of a mild fluid pill.)
  • Pump flanges that don’t fit correctly. Ask a lactation consultant to check and make sure you’re using the right size. Flange size can change over time.
  • Going longer than 3 hours since the beginning of the last feeding/pumping session. If the feedback inhibitor of lactation stays attached to prolactin receptors longer than 3 hours, that section of the gland may get turned off until the next baby.
• How well you get emptied out can also be affected by how strong your milk ejection reflex (also called “let-down”) is. If your let-down is inhibited or blunted for some reason, like pain or stress, you may not get emptied out well. See #5 and #8. One homeopathic remedy that works well for encouraging the let-down is Bach’s Rescue Remedy combined flower essences. Follow label directions.
• Some other factors can enter into the equation: anemia, stress, getting your period back, dehydration, thyroid problems (too high or too low), getting pregnant again, various medications, and even some herbs. There are other rare problems that a Breastfeeding Medicine specialist (doctor who specializes in Breastfeeding Medicine) can check for.
• Baby starting solids can decrease milk supply, if solids are given before breastfeeding, because baby won’t be as hungry, and won’t take as much milk. Since baby is supposed to get most nourishment from breast milk until his birthday anyway, don’t be in a hurry. Wait until about 6 months. Always breastfeed BEFORE giving solids. Use them to add to baby’s perfect diet, not replace part of it!
• Other things to avoid, to keep supply from dropping:
  • Delaying or skipping feedings or pumping sessions. This is by far the most frequent cause of decreasing or low milk supply. And if baby won’t or can’t breastfeed for some reason, pump until you’re empty, at least every 3 hours!
  • Hormonal types of birth control, including pills, IUD’s, and Depo-Provera shots, especially in the first six weeks after delivery.
  • Other Medications to avoid—cold remedies with the ingredient pseudoephedrine, some antihistamines, medications for Parkinson’s Disease, and most medications for Restless Legs Syndrome.
  • Herbs to avoid, whether in cooking or as ingredients in herbal medicines— sage (all types), parsley, rosemary, thyme, strong mint (all types).
  • Smoking – tobacco is one of the “herbs” that can cause a drop.
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There are things that can be done to increase your milk supply, including some herbal remedies and some medications, but those are best discussed with a Breastfeeding Medicine specialist.

He or she will

• Take a complete medical history, to assess other possible reasons for a low milk supply, as well as possible contraindications to pharmaceutical or herbal galactogogues and/or medical interactions.
  
• Perform a breast exam to check the state of your glandular tissue.
• Check your baby’s oral anatomy to look for reasons why baby may not be latching or suckling properly.
• Observe a breastfeeding session and possibly perform a test weight to measure how much milk baby is getting.
• Observe pumping to check for let-down and flange fit and to measure residual milk that the baby didn’t get.
• Make recommendations for your specific needs and situation.

Resources

www.breastfeedingmadesimple.com
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www.medela.com