PCOS and Breastfeeding

Recently Deseree, a third time mom with a history of PCOS, asked a question about how to avoid a milk supply problem when her next baby is born.    To summarize, she has attempted breastfeeding twice, both times her breastfeeding started out well with initial physiologic engorgement, her milk “came in” and the babies were eating well.  At two weeks old however her babies were not gaining weight.  She is now 37 weeks pregnant and wants to know what she can do to prevent a third disappointing breastfeeding experience.

First it is important to say that what Deseree needs most is a supportive and knowledgeable lactation consultant who can complete a full history and breast exam to rule out the most common problems.  Since the problem happened for both of her children I will assume that the issue is maternal and not a newborn issue, but that is just an assumption.  Deseree, it is important that you first look for the low hanging fruit; are you eating a balanced diet (Vegans, women with absorption issues, gastric bypass patients all are more likely to have an infant with slow weight gain).  Next I would like to do a complete physical exam to rule out breast issues, hypoplastic breasts or those with inadequate glandular tissue would also raise a red flag.  Finally, I think it is important to ensure that breastfeeding begins on a positive note with as few barriers and booby traps as possible.  I always recommend prolonged, uninterrupted skin to skin contact until breastfeeding is well established.  Assuming that all of the easy fixes have been addressed, I think the most likely source of your trouble is polycystic ovary syndrome (PCOS). 

Polycystic Ovarian Syndrome is an endocrine disorder that affects up to 15% of women, it is marked by irregular menses, infertility, recurrent pregnancy loss, facial hair, acne, and a host of other interesting symptoms brought on primarily by excessive androgen production and insulin resistance.    Of course anything powerful enough to cause all of those hormonal disturbances in a non-pregnant woman can certainly wreck havoc on a breastfeeding mother.  There is good evidence that PCOS can lead to breastfeeding problems, particularly problems with inadequate milk supply.  The best source of information I have on this problem is Diana West and Lisa Marasco’s excellent book “The breastfeeding mother’s guide to Making More Milk” (McGraw-Hill, 2009).  This source has a comprehensive section on PCOS and how to help improve breastfeeding success.  There is a medicine that your doctor can prescribe called Metformin.  This drug helps the body process insulin which will, in turn improve milk supply.  I recommend starting it as soon as possible and begin pumping at 38 weeks to stimulate breast growth. 

If your doctor is unwilling to prescribe metformin, or if you want to try a “double whammy” you can also take a couple of herbal supplements.  Goat’s Rue (actually contains a precursor to Metformin called Guanidine) has been shown to increase milk production in dairy animals by 35-40% and stimulate breast growth.  Goat’s Rue can be taken as a tea (1 tsp of leaves steeped in one cup of water for 10-15 minutes 2-5 times a day), a tincture (there are several available doses, you will need to get with an herbalist to find the best dose and brand available but they range from 1-4 ml up to 4 times per day), or as a capsule from Motherlove taken four times a day).    Another herbal supplement to use in conjunction with Goat’s Rue is Marshmallow Root.  Marshmallow root is believed to enhance the effectiveness of Goat’s Rue and may enhance the richness of your milk.  It can also be taken in a tea (1 tbsp in 5-8 ounces of cold water allowed to stand for 30 minutes), a tincture (1-4 ml three times a day), or a capsule 2-4 capsules three times a day).    Consult an herbalist for the best product available to you. 

Finally, if it comes to having to supplement your baby it is vital to remember that breastfeeding does not have to be ALL OR NOTHING.  You may find that your baby needs a little more than you have to offer, but if that becomes necessary I recommend using a supplemental nursing system (SNS) which will allow your baby to continue to breastfeeding (thereby stimulating milk removal, breast growth & development, and increasing milk supply) while also encouraging your infant to achieve robust growth.  I often use the analogy of walking when I talk about breastfeeding difficulty.  No parent would ever accept that their baby just didn’t or couldn’t walk.  Rather, a five year old who is struggling with walking is offered physical therapy, braces, assistive devices, walkers, crutches, and every manner of surgery and medical treatments.  Some children actually need help with walking and they get it.  No mother would simply say “My baby didn’t want to walk, so I bought her a wheelchair.  What’s the benefit to walking anyway?”  But replace “walk” and “Wheelchair” with “Breastfeed” and “Formula Feeding” and you a lactation consultant hears that almost every day.  No, it doesn’t have to be ALL OR NOTHING, if it isn’t perfect, it is still breastfeeding. 

I’m sorry that it took me this long to reply, if you have any other questions or concerns, please don’t hesitate to ask.

Congratulations Dad! Happy Father's Day

Today is Father's Day, enjoy.

Congratulations new father and fathers-to-be. What awaits you is a wonderful journey, rich in rewards and joy. Fatherhood is more than creating a new life; it is the creation of a family. Any man who has gazed deeply into the eyes of his beautiful child knows the joy hidden there.  Now that Father’s Day is here, I want to speak directly to you, one father to another, about your pivotal role in supporting breastfeeding.

Being a father is a demanding job. No longer can a man be content to provide financial support to his family and call it a day. Today’s father is expected to be a team player with the mother of his children. He is required to shoulder an equal load of child care; he is expected to be wise, an ardent supporter of his family, and a source of inspiration, love, and advice.

These days, perhaps more than ever before, men find themselves wanting to take an active role in their children’s lives. We attend antenatal appointments, childbirth and breastfeeding classes. We are openly invited into labor and delivery and actively engage in the birth, we are encouraged to cut the umbilical cord, and to spend the first days in the hospital with our new family.  We are there from before the beginning and plan to be there until the end. But many of us know very little about the process and even less about what to do when we hold that beautiful little baby in our arms for the first time.

In today’s digital age, filled with instant satisfaction, and a constant desire for news, families face pressure to share the details with the world immediately.  Everyone wants to know how much the new baby weighs, how long he is, they want a picture, a Facebook post and even regular Tweets. Often the first few days are a blur of sleepless nights, an endless parade of well-meaning health care staff trying to teach you everything, days filled with visitors, demands for information and, when we can fit it in, child care. When that time comes ask yourself, “What are my priorities?” Are you there to meet the needs of your wife and child or of those around you? The answer is obvious. So go to it. Limit visitors, turn off your devices; the details can wait a few days, and recommend to friends and well-wishers that they bring you dinner next week rather than visit in the hospital. Encourage your partner to rest, and help her to avoid distractions that steal precious time away from her most important job, mothering. A father has always been looked upon to support and protect his family. To many of us, it is our greatest joy in life. Do that and everything will fall into place. We instinctively know what to do; all we have to do is listen and our soul will tell us what to do.

Take an active role in supporting the breastfeeding relationship between your partner and child. Breastfeeding is the most wondrous thing that a mother can do for her children. Today, more than 75% of new mothers intend to breastfeed, but less than half of them are successful. A major cause of such wide spread failure is a lack of timely information. Too often there is no one around to help when mom needs it most. You can be that helping hand that your partner needs, you can be up to the task. You, my friend, are the coach. You are a source of information, guidance, and motivation.  Your job is to make her job easier. All fathers need to know the basics and reinforce what the mother hears, to counter bad advice, and troubleshoot. Remember Dad, you are the only one who will be there at 3 AM when your beloved has questions.  You can’t feed the baby, you don’t have breasts, but you can help her feed the baby, and that will make all the difference. You are the one that she trusts, she loves, and ultimately, you are the one that she will listen to. When you are well prepared, supportive and engaged, you and she will find success. 

So what do you have to do? The three most important questions you have may be: When does your baby need to breastfeed? How does your baby breastfeed?  When will your baby be finished breastfeeding? The answers to these questions are often detailed. Take the time early on to ask your midwife or breastfeeding supporter these questions. Get the answers, remember them, and use them when the time is right. Be prepared to help your family breastfeed. Learn the signs of a good latch (nose and chin touching the breast, puffy cheeks, wide open jaw, flared lips up and down, and no pain). Learn the steps that can be taken to fix a bad latch, and learn how to tell that your baby is taking breastmilk. Have the telephone numbers of your LLL leader and IBCLC handy.

 You are the coach, the support, the source of information, and the emergency advice line. Now it’s over to you. Get to work!

Fathers and Breastfeeding - Just pull SPORTS

Welcome back.  This is the second part of a two part series on the role of the father in breastfeeding.  In the first article we explored each team member’s role in the breastfeeding relationship.  We talked about Mom’s job, which is to put the baby to the breast, to offer the breast, and love the baby.  We talked about the Baby’s job, which is to put the breast in his mouth, suck and swallow until satisfied, and love mommy and daddy.  We talked about Dad’s job which is to take over the job of the lactation consultant when the family goes home.  The father is the one who will be available to answer questions at 3 AM.  The father is the one that mom trusts, she listens to her partner much better than she listens to her lactation consultant.  Many mothers struggle with confidence when breastfeeding, they doubt the baby’s desire to breastfeed, they doubt their families support for breastfeeding, and most of all they doubt themselves and their abilities breastfeed.  A new mother struggles with confidence almost every day and her shaky confidence is easily destroyed by a doubting father.  When you say something stupid, like “I don’t know honey, maybe we need to give him a bottle”, you have just damaged your family’s chances at breastfeeding success. 

So, if you’ve come this far, your still with me and it’s time to learn how to breastfeed.  I break it down into three simple steps.  1) When does the baby need to eat?  2) How does the baby eat? 3) When is the baby done eating?  It really is that simple, so let’s dive in.

When does the Baby need to eat?  First thing you have to understand is that in all my years working with families, I’ve never met a baby that read the rule book before birth.  A baby does not eat for 10 minutes on each breast every 2-3 hours.  What nonsense!  Babies are not born with watches, and even if you give him one, he can’t read it anyway.  When a baby has stress (hunger, cold, wet or dirty diapers, pain, or loneliness) he will show you some very predictable signs.  He’ll curl up his hands and feet and bring them to the center.  He’ll bend at the knees and cross his feet or put his heels together (that’s called centering behavior).  He’ll start to turn his head and may suck on his hands.  Eventually he’ll start to fuss and finally cry.  All of these are stress signs.  Sometimes he’ll be hungry, sometimes lonely; but when he does those things he is asking for you to pick him up and tend to his needs.  Since you won’t know what he wants by looking at him, I always recommend you start in the kitchen (AKA – the breast).  If he’s hungry, he’ll take the breast when you offer it.  But never insist that a baby “has to be hungry” just because it’s been a while since he’s had the breast, and the opposite is true as well.  Don’t automatically assume he can’t be hungry just because he only ate an hour ago.  Babies are unpredictable, but when you offer the breast, he’ll eat if he’s hungry.  As a general rule, newborns eat 8-12 times a day, usually in clustered groups of 3-4 times in a four hour period, they then take a 3-4 hour nap and start over again.  Don’t count on it, but know that while no two babies eat on the same schedule, very rarely will a baby actually eat for 10 minutes on each breast every 2-3 hours, as most books would suggest. 

How does the baby eat?  This is a tough one; every baby is different, just like every person is different.  But there are a few simple principles that you can follow.  When baby is ready to eat and he’s in the kitchen, he will stretch out his hands, move the breast to where he wants it, open his mouth VERY wide, and take the breast deep into his mouth.  He’ll latch on well, he’ll suckle in bursts of rapid sucks followed by a short pause, you may hear a soft quiet swallowing sound, and then he’ll do it again.  Sometimes he’ll appear to be sleeping, as he lies peacefully on the breast while holding the breast in his mouth.  Don’t be fooled, babies don’t really sleep on the breast; they rest and wait for their drinks to settle in their stomach.  I am fond of saying “Only college students and Army Privates like to chug” everyone else takes a few sips then puts their drink down, then start again.  Don’t expect him to chug his milk and get it over with quickly, he wouldn’t expect the same from you. 

When your baby is on the breast you need to make sure he is latched on well and that he is transferring milk well from mom to baby.  Every time your baby latches on, you will need to look for signs of a good latch, and here they are:

1)      Nose and Chin touching the breast.  He should burry his face deep in the breast, never try to pull the breast away from his face because that will pull the nipple away from him mouth, or change the shape of the breast in his mouth.  Never fear that he will suffocate on the breast.  First, remember, he isn’t stupid, he won’t suffocate for one more drink of breast milk, if he can’t breathe, he’ll just turn his head or pull away.  Second, have you ever noticed the creases on the side of your nose and how they tend to run up to your eyes?  Have you ever noticed that there is a dimple on the side of your head where your eye sockets are?  That is a continuous channel from the nose to the side of the head that I call “The Baby Snorkel System”.  Air moves from his mouth, to his eyes, under his eyes and out the side of his head.  If you don’t believe me put your face underwater, cover your face with your hands and blow air out of your nose, you’ll see the air move out of the side of your head. 

2)      Full Round Cheeks without dimples.  If his mouth is full of breast, his cheeks are full of breasts.  If you see dimples on his cheeks or creases around his mouth, he does not have the breast deep in his mouth and he is creating a vacuum of empty space, and he is hurting your lovely bride.

3)      Wide Open Jaw.  The infant has a small mouth and he has to open that mouth VERY wide to get all that breast tissue deep into his mouth.  Get ready, here’s where you get to measure something.  If you measure the angle from his nose, to his ear, to his chin that angle should be greater than 60 degrees, but 90 degrees is even better.  I recommend using your fingers, put your index finger on the nose, your palm on his ear, and your middle finger on his chin, and measure that angle.  45 degrees is a closed and empty mouth, and that hurts!

4)      No Pain.  NO PAIN! NO PAIN! NO PAIN!  Did I mention it shouldn’t hurt to breastfeed?  Traditionally, nipple pain in early breastfeeding was considered normal and unavoidable.  That is a myth whose time is long past.  New understanding of the anatomy of breast milk structures in the nipple and areola shows that there is no fat or cushion in the nipple and that all cushion is held back on the areola.  When the infant pinches the nipple with his mouth or tongue your wife will get pain, which is exactly the same thing that will happen if you pinch the nipple with your thumb and forefinger.  Pinching the nipple is always a bad thing and mom wouldn’t let you do it either!  If you can’t get away with it, neither should baby.   Not only will the baby hurt his mother, but he will also not be able to effectively bring milk out.  When you pinch the nipple, you bend the tubes that bring down breast milk.  Just like any other straw, if you bend it you can’t drink from it.  Don’t let the baby bend those tubes or pinch the nipple.  If your wife has nipple pain, you need to fix the latch immediately, and if you can’t, you need to get in to see a lactation consultant as soon as possible.

5)      Flared Lips, Up and Down.  In order for a baby to take the breast deep in his mouth he will have to flare his lips as he opens his mouth widely.  His tongue will extend and push out his lower lip, and he will wrap his lips around the areola.  If there is a latching problem it is often failure to flare the bottom lip.  All that being said, when he is properly buried into the breast you can’t see his lips.  Know that if everything else is okay, the lips are probably okay.  But if there is pain, dimples in the cheeks, or a narrow jaw, you will need to help your baby open his mouth and push his bottom lip and tongue out.

But how do I do that? One may ask.  Don’t worry I’ll show you.  Now, I’m a soldier, I’ve been a soldier my entire life, and a soldier I use soldier analogies when I teach.  If any of you have ever served in the Armed Forces, you will get this next bit well.  If not, I’m sorry in advance.  When a baby has a bad latch, it is almost always a double feed. You have two rounds in the chamber at the same time (in this case, breast and lower lip).  And just like any other double feed, you’ll have to pull SPORTS (slap, pull, observe, release, tap, and shoot).   If you’ve never been in the military, don’t worry, just remember SPORTS, guys like sports so we can use that to help you remember the steps to fixing a bad latch.

 

S – Slap – Put your hand on the baby’s back and push him toward the breast (don't actually slap him, just press him into the breast).

P – Pull – Reach in between the chin and the breast and pull down on the baby’s chin to elicit a rooting reflex.

O – Observe – Does it work?  Does the jaw open, do the cheeks fill and round out, do the lips flare, and does the pain go away?

R – Release – let go of the chin and let the baby suckle and test the new latch.

T – Tap/Try again – Repeat the first four steps two or three times to see if you can correct the bad latch.

S – Shoot – Darn it! We have to take him off the breast and try again. 

If you can’t fix the latch with the basics of SPORTS you are going to need remedial action.  You’re going to have to drop the magazine (take the baby off the breast), clear the chamber (calm the child then elicit a rooting reflex off the breast to encourage a VERY wide open mouth), and reload (put him back to the breast). 

Eventually these steps will almost always help solve a bad latch.  Very rarely you may find that even though you do everything right your baby will not latch correctly.  He may have chosen to sleep rather than eat, he may be over stimulated, or he may just need an experienced hand to help him out.  Give him a break, let him rest for an hour or so, and try again.  If he ever goes 24 hours without eating, get in to see a lactation consultant right away. 

Finally, When is my baby finished eating?  When baby is finished eating he will relax his hands, release the breast, pull away from the breast, and fall into a deep sleep that I call “The Milk Coma.”  Remember, your baby can’t tell time.  Some babies will finish the breast in 10-15 minutes; some will finish the breast in 45-60 minutes.  Both babies will have taken the same amount of milk, and that amount is “ENOUGH”.  There is no easy way for you to measure how much a baby eats when he is on the breast, but know that the actual amount of ounces he drinks is immaterial.  What is important is that he goes to breast interested in feeding, and that he pulls away content, relaxed, and sleeping.   A baby that is satisfied after feeding, growing steadily, looking healthy and is generally a happy baby, is almost certainly getting “enough” to eat.  The number one concern of new mothers is that they do not make enough milk.  Try not to worry about it, keep offering the breast to the baby, and he will always get enough to eat. 

Now that we’ve covered feeding, let’s talk about sex while breastfeeding.  You may be afraid to ask, so I’ll tell you.  Breastfeeding (and for that matter, parenting) will impact your sex lives.  Both of you need to know that some mothers have an increased libido (thanks to repetitive oxytocin surges), while others have a decreased libido (thanks to prolactin and a decrease in estrogen).  Fathers may face problems with the “Madonna Complex” (She’s a mother now).  All of this will impact your sex live, but perhaps what is most important is for fathers to understand that all aspects of parenting, are demanding, physical work with only short bursts of sleep interrupted by a newborn that demands attention at inconvenient times.  Mom will need constant support and help from her lover.  The more help she can get from her husband, the more energy she will have for other activities.  In other words “You’ve got to give a little, to get a little.”

So there you have it; breastfeeding from a man’s perspective.  Fathers are powerful allies contributing to breastfeeding success.  Do not allow yourself to be excluded from this time in your child’s life.  Study and learn, roll up your sleeves and get in the game.  Your family stands a much better chance of success if you actively support breastfeeding and actually help your wife breastfeed.  

Fathers and Breastfeeding!!

Its finally here!!  Father's Day is right around the corner.  Time to talk about my two favorite topics, Dads and Breastfeeding! I think that in honor of Father's Day I'll post three posts, rather than just one.  Friday and Saturday I'll talk about Breastfeeding, then on Sunday I'll post something with a little more love and little less work. 
 Here comes #1

If you are reading this column, you and your wife are probably expecting a beautiful baby, to which I say congratulations!  You are already well on your way down the path of parenthood.  Make no mistake you become a parent long before your baby is born, just as your child knows both mom and dad long before he or she is born.  The road that you are on will be tough; it will lead you through countless trials and conquests, ups and downs, and twists and turns.  I am very fond of saying that parenting is a contact sport, but the rewards are tremendous.  Each new skill, each new word, every new step you experience as your child grows is an exciting and miraculous journey down the road of life.  Enjoy the journey, the hard times and the easy times.  Nothing in life compares. 

There is so much to say about your role in breastfeeding that I just can’t squeeze it in to the space limitations of one article, so we will look at the role of the father in two parts.  The first part will explore the roles of each member of the breastfeeding team (Mom, Dad, and Baby).  The second part will actually get down into the mechanics of breastfeeding.  You will learn to assess what a “good latch” looks like and help you develop the skills you will need to help your family breastfeed.

As a midwife, a lactation consultant and a father of eight (your read that right, 8) beautiful breastfed babies I’m often asked to share my perspectives with new parents.  First, let me say, I have found through personal and professional practice that almost everything is hard the first few days or weeks with a new baby and breastfeeding is no different.  You will do yourself a favor if you prepare for the challenges ahead by learning all you can before your progeny is born.  I encourage you to talk to your health care provider, your lactation consultant, and especially friends who have successfully breastfed for more than six months.   Learning from successful and experienced breastfeeding friends is a good way to get honest accurate information and avoid the myths that make breastfeeding so very challenging.  I warn you to ignore the advice of couples who failed at breastfeeding, as their perspectives, while honest, may not always be accurate.  Nothing teaches better than success. 

Before we can talk about your role in breastfeeding, we have to answer the most fundamental question in the breastfeeding, why would anyone want to breastfeed?  In the old days we used to talk about the benefits of breastfeeding, and you will still hear some people mention it, but not me.  Believe it or not, breastfeeding doesn’t make your baby bigger, stronger, faster, or smarter.  Breastfeeding doesn’t make him super human, it just makes him human.  The problem is that formula is incomplete nutrition, it is missing several essential nutrients that a growing baby needs.  Formula feeding makes your baby weaker, slower, and dumber than his breastfeeding counterparts.  Many people become offended at the notion that formula feeding is substandard nutrition, you will hear them defend their formula feeding history, but there is no hiding the fact, incomplete nutrition will always affect your long term health.  There are indeed risks to formula feeding, just like there are risks to eating fast food every day.  If you eat fast food three meals a day for two years you would be weaker, slower, and dumber too.  There is no doubt about it, inadequate nutrition is inadequate growth.  Breastfeeding is perfect nutrition and as a human mammal your child is designed to drink human milk made especially for him, by his mother.  If you don’t believe me, there are more than 4000 well designed clinical trials, and hundreds of other sources to prove my point.  Honestly, if you don’t think that formula is substandard nutrition you have been purposely hiding from the truth and nothing I say here will help change your mind. 

You will notice that I have taken great pains to welcome dad into the breastfeeding relationship, and I do that for a good reason.  The only person with more influence over a mother’s breastfeeding success than the father is the baby; and baby is already on board with this “choice” it is all he wants to do.  The value that dad brings to this relationship is often underplayed.  When you watch TV, read stories, or even read your wife’s precious pregnancy books you will be hard pressed to find much useful information on dad’s job in breastfeeding. Most of the medical and nursing personnel you will meet assume that the father is either not able to help with breastfeeding, or simply not interested.  All the research available shows that they are wrong.  As the father of the 21^st Century I know you are smart, able, and interested in helping to make motherhood and breastfeeding as easy and successful as possible.  I am certain that you are not only interested in breastfeeding but that you are uniquely talented at it.  Mothers consistently rate their husband’s support as the most important contributing factor to breastfeeding success.  The father is more important than grandmothers, best friends, you are even better than nurses, doctors, and lactation consultants.  Together, the mother, father, and baby will work to form a successful breastfeeding family.  To enhance your family’s chances of success everyone has to work together and focus’ their efforts on successful breastfeeding.    So, let’s talk about each member of the team.

The Mother’s job is to put the baby “in the kitchen”.  That means that mom has to offer the baby the breast.  You will notice that I didn’t tell you that a mother feeds her baby, because she doesn’t.  The baby will feed himself.  I always recommend (at least for the first few days or weeks) that the mother take off all the baby’s clothes and put his naked chest right up against her bare chest, once they are “skin-to-skin” cover the two with a blanket.  That way the baby stays warm, and the mother stays modest.  With the baby in the kitchen, all you really have to do is wait for him to do his job.  If you really feel the need you can coax him to nurse.  You can talk to him, pet him, stroke his face and mouth and encourage him to feed, but ultimately the baby knows what he’s doing and all you really have to do is be patient. 

The Baby’s job is demanding, but the healthy newborn is well prepared at birth.  The baby has to identify the breast, he will wrap his cute little hands around it, put it where he needs it to be, open his mouth VERY wide and take the entire areola deep into his mouth, down his throat and suck and swallow until satisfied.  The more breast tissue a baby takes in, the easier and more effective feeding will be.  Remember, it is the baby’s job to feed himself.  He is bright, energetic and ready to feed himself very soon after birth, usually within the first 48 hours.  Don’t rush him, being born is hard work and he is very tired after the adrenalin of birth wears off.  If your healthy baby sleeps from 4 hours of life until 24 hours of life, he is still a normal newborn.  Mom, all you really have to do is hold him close, keep him “in the kitchen” and allow him to do what he needs to do.  Your healthy newborn will surprise you, I promise.

The Breastfeeding Father has the hardest job in the family.  I hate to say it, but it is true.  But have no fear; I know that you are man enough to breastfeed for your family.  Dad, your job is to do my job when you take your lovely new family home.  When your bride wakes up at 3 in the morning and needs help getting your progeny to the breast, she won’t ask me or her midwife to help get the baby on, she’ll ask you.  When you go home, the spotlight will be on.  You are a powerful team member and your team will have a much better chance to succeed if you are actively involved.  So get in there, roll up your sleeves and breastfeed.  Don’t worry, I’ll show you how, in part two of this series which I will post tomorrow.  So hang in there, only 12 hours or so.

 

Sage Homme

 

 

Co-Sleeping

I posted this quick little dittie on my facebook page today and felt compared to cross post it here as well.  Enjoy.

So Debbie asked:  “What exactly do you tell your families about co-sleeping”

I tell my families a lot of things.  Elizabeth Johnston and I once wrote an editorial on the topic (“On Co-sleeping”, JOGNN 2008).  In that piece we point out that 75% of North American mothers sleep with their babies and lie to their pediatricians about it (about 10% more don’t bother to lie).  That means that more babies sleep with their parents than the “sleep alone” crowd will admit to and that more babies die alone in cribs every year than die sleeping wrapped in the loving arms of their mother, despite the fact that fewer sleep alone in cribs.

  I tell them that there are four rules to safe sleeping, and they are the rules of James McKenna:

1)      Only Mommy and Daddy sleep with babies.  No aunts, uncles, brothers or sisters.

2)      No one sleeps with baby if they have drugs or alcohol on board, and I’m not a big fan of smoking either, as that also significantly increases the risk that your baby will die in his sleep.

3)      No one in the bed can weight more than 300 lbs.

4)      Only sleep on a firm, flat, familiar sleep surface.  Not on a couch, a recliner, a waterbed, a hospital bed, etc…

I add one more, and that is breastfeed.  Over and over again we see that formula feeding increases the risk of infant death and yet that is nowhere in the AAP safe sleep guidelines (or at least it wasn’t until very recently).

I point out that in the last two versions of the AAP policy on the Use of Human Milk, in which they recommend “Baby should sleep ‘in close proximity’ to the mother”, they studies that they use to point to that major change in parenting styles is based on CO-SLEEPING studies.  It isn’t based on research where mothers put a crib in their bedrooms at night, no.  The studies were using bed sharing and side car sleepers vs. separate sleep surfaces.  So they admit that bed sharing is the better option, but they refuse to accept that their theories are wrong and insist that babies sleep alone.  They use co-sleeping studies to suggest that it is better and safer and then tell you not to co-sleep with your infant.  If we want to save lives, we have to admit that our theories may not be correct and our core beliefs may be flawed.  If we haven’t the courage to explore our sacred cows, we won’t ever be able to advance.    

I was stumbling through the internet today and came upon a mother in waiting with breastfeeding questions.  She asked five questions, but all of them were the same.  “CAN I BREASTFEED IF…?”  I tried to answer, but my response was too long, so I put it here instead.  Enjoy. 

My first word of advice is to find a good lactation consultant.  It helps to have someone who you can talk to, who listens to you when ask questions and can help you find real world solutions to your real world issues.  That said, I love to answer questions about breastfeeding and will gladly try my hand at yours. 

“Can I breastfeed if…?” This is perhaps the most common question I get from pregnant women.  The answer is simple, YES.  You can breastfeed even if you are infertile and have never been pregnant.  You can start breastfeeding one month after the baby is born because you change your mind.  You can breastfeed adopted children and other people’s children.   You are a mammal and the only biological reason for having breasts is to nurse your offspring.  That said, there are things that are known to throw up barriers to breastfeeding, actions that work against your efforts and make all but the stout hearted mother throw in the towel.  A new mother is sore, frightened, filled with doubt, tired, and just plain vulnerable.  Often left alone to her worst fears she reaches for the only “safety net” she can think of, the bottle.  And that is where the trouble starts.  Almost every obstacle can be overcome but the recommendations made by lactation consultants are an attempt to prevent these obstacles and make things as easy as possible for every new mother.      

1.  Can I successfully breastfeed with medical interventions during delivery?  Yes, but for every intervention there is a price to be paid.  While many interventions (fetal monitoring, artificial rupture of membranes, intrauterine pressure catheters, etc…) have no effect on breastfeeding, others affect breastfeeding in hidden insidious ways.  Some are obvious; Narcotics in the blood stream pass to baby and make it very difficult for your baby to breastfeed for the first 1-2 days because he is literally high as a kite.  Epidurals seem to have a similar affect although not nearly as powerfully and the literature is conflicting (principally because the studies are measuring several different things in different ways and attempting to answer the same question, don’t get me started), just take it from a midwife and lactation consultant who has helped thousands of new mothers breastfeed, there is no comparing the baby born of natural childbirth to those born from medicated births.  Some are more insidious; mothers who take more than 3 liters of IV fluid have babies who are more likely to lose more than 10% of their birth weight which leads pediatricians (and mothers) to worry that the otherwise healthy infant isn’t eating, even if it is obvious that he is.  Simply put, every intervention is a potential barrier to breastfeeding, the fewer you allow to be placed in your way, the easier breastfeeding will be.    

 2.  Can I bf even if I don't co-sleep?  Yes, not everyone co-sleeps.  Although technically I think the term you are looking for is “bed-share”.  The difference is small but important.  Co-sleeping means the baby is nearby (perhaps a cradle next to the bed or a side-car sleeper connected to your bed).  Bed-sharing is sleeping in the same bed, most women bed-share with their husbands and many choose to co-sleep with their infants.  That said, studies show that women who sleep with their infants in the same bed breastfeed easier, sleep deeper and are more rested upon waking, and interestingly enough are more alert while sleeping.  It is a paradox that the mother (I frequently refer to mothers as super-human) can sleep both deeply and alertly and wake feeling refreshed.  Can you breastfeed when your baby is in another room, certainly but you have to wake more fully to go get him and sleep less soundly which makes you more fatigued during the day and that makes everything more difficult.  So yes, you can, but it just makes your life harder.    

 

3.  Can I bf, while still offering bottles of expressed milk?

 Again, of course you can, but bottles of expressed breastmilk are detrimental to breastfeeding success for most women and until you become a cow they are just plain hard to come by.  It is important to understand that the bottle is not the breast.  Bottle fed infants often take in much more than they need or want (did you know a newborn’s stomach is so small that it only holds one teaspoon?).  That is because gravity feeds the bottle fed infant, not the infant.  The infant must swallow or drown, and that is why they vomit so often.  While certainly, spit happens, it happens far more often on a bottle fed infant and primarily due to over feeding, not the liquid that is fed.  That over feeding wastes precious milk and leads mothers to think that the baby wants more than the mother can produce.  This is coupled with the fact, as I alluded to before, you are not a cow.  A woman’s breast is complex and I can’t just hook you up to a milk machine and make milk come out (believe it or not).  Pumping is no substitute for breastfeeding and many (dare I say most), will find they get out less than half of what is actually in the breast.  Some women are pump depended, and some can pump very well, but many find that pumping is difficult and depressing.  So yes, you can offer expressed breastmilk but it is difficult and puts a barrier in the way to successful feeding. 

4.  What should I expect in those first few weeks?  I forget what it was was like or more likely, I blocked it out.

Many women will tell you that the first few weeks are difficult.  I am frankly baffled at that idea.  The baby sleeps up to 20 hours a day, how can we possibly not get enough sleep?  Now, before you get offended, “You’re just a man, how can you possibly know?”  I am the father of 8 children, I am a midwife (not a mid-husband), and I am an IBCLC (lactation consultant), mothers and babies are my life.  What I find is that being a mother is not difficult, you are super-human, you have super powers that make mothering rather easy in the first few days HOWEVER, most new mothers do not allow themselves to only be a mother.  The first few days are an endless stream of visitors and well wishers, doctors, nurses, audiologists, pediatricians, in-laws, out-laws, cousins, neighbors, Facebook posts, tweets, phone calls, and every other person under the sun.  It is that never ending stream of visitors that makes life hard on the new mom and dad, not the one little baby.  I recommend that new parents forgo the world, close the door with a “NO VISITORS” sign and tell everyone to leave them alone.  Tell them that if they really care about you and your baby they will leave you alone and bring you a hot dish next week.  Your baby needs to spend as much time on your chest as humanly possible, preferably naked and skin to skin.  He will attempt to suckle up to 10 times an hour.  It is very much like a child learning to play the piano by practicing scales.  They don’t make music, they learn the basics first and the music comes later.  But when baby sleeps, mommy and daddy sleeps.  Sleep in shifts, it takes two people to make a baby because it takes two people to take care of a baby.  If you already have children, you are a more prepared set of parents and it will come even easier to you, you can tag-team the newborn and the other children.  Believe me, I know, from which I speak.   

5.  Do I have to be completely attached to baby 24/7?  A shower alone or a walk with Isabella sound pretty important to me?

Again, no, but it sure makes life easier if you are.  Let’s take a look at the animal kingdom for a second.  What happens if you take a gorilla’s baby away?  They lose their mind.  This instinctual need to be near your newborn makes mothering very easy.  You don’t have to be joined at the hip, of course you need time to pee, and a shower sure feels wonderful after a hard night.  But keeping separation to a minimum in the first few weeks of life makes everything easier. 

My biggest problem in the hospital is that mothers do not hold their babies unless I give them permission to do it.   It seems odd and even counter-intuitive, but it is true.  I am frequently called to help a new family with breastfeeding and almost every time I walk in the room someone else is holding the baby.  Baby is wrapped tightly and in Grandma’s arms, auntie’s arms, daddy’s arms, all those “well wishers” who do nothing but make your life miserable are holding YOUR baby.  

Often the baby is wrapped up like a burrito and stuffed in the Tupperware drawer (the bassinette), and no one is holding the poor thing.   When I ask mom why she isn’t holding her baby she often (no kidding) will say “I didn’t know I could.”  That is your baby!!  He isn’t the responsibility of the nurses or the doctors, he is yours, you had him, you will raise him, do with him as you please.  We are visitors in your world, not the other way around. 

All questions about “ownership” and parental rights aside, let’s get down to brass tacks.  How can your baby learn to breastfeed if you never let him practice?  It is like hanging him from the ceiling and wondering why he doesn’t learn to walk.  So yes, babies need to be held, they are miserable when they are not in their mother’s arms.  Yes, you can leave him with daddy or grandma for short periods of time, but ultimately you are the only one in the world who can give him what he needs.  You are the only one in the world who can offer him that life giving nourishment.  Just like only mommy can push him out, only mommy can bring him up.  Love him, hold him, and everything else just naturally falls into place.

Questions about making milk

Today, I got three questions that deal with milk supply issues.  This is the most common fear of most new mothers and the number one reason that women stop nursing before they planned.  It is also, in my humble opinion, very rare that the breasts actually fail.  I call it “Acute onset idiopathic lactation failure” and frankly, it just doesn’t happen all that often.  I hope to make this the source of my PhD work, but I’m having a little trouble convincing the Army that it is important.  So anyway, I’ve combined all three questions into one post.  I’m sorry it is a bit long.  But that’s what you get when you ask a doctoral student about his thesis. ;)

Nicky asked: “I breastfed with my daughter who is now 18mths, I know there were times that I was worried she wasn’t getting enough milk but because her weight was increasing they told me I had nothing to worry about, She ate every 2-3 hrs. I now have a newborn who I feel is attached to me, He eats every 45 min- hr for like 20 min then sleeps. The last apt we had was the 2day apt and he had gained an oz. I have another apt this week, but I’m worried (not stressing, because he’s got poopy/ pp diapers) that he’s not getting enough.  Should I be worried and talk to someone, or should I wait to see if he’s gained any before I seek help.  Also my daughter had no problems feeding ( didn’t hurt or chap or anything) where as I feel I had to teach him a little, but when he latches it hurts at the 1st latch on then I’m fine, Is this normal?”

Nicky,  Congratulations on the birth of your new baby.  The first few weeks are a tough time, made worse by our incessant need to worry all the time about everything.  It sounds to me like you and your baby are getting along just fine.  You tell me that he is peeing and pooping and that he has gained an ounce (I assume since discharge, but if it is an ounce over birth weight he is a rock star breast feeder), all of this is reassuring. Given your first successful breastfeeding, it would put sudden unexplained “I can’t make enough milk” at the very bottom of my list of things to worry about.  You know that your breasts work.  Trust them.  I would suggest that everything is going on well enough.  That being said, you also put up a couple of little hints that things aren’t going perfect (the frequent feeds and the tender nipples), so let’s address them. 

Frequent feeds and tender nipples are both signs of a less than perfect latch.  You see, when the baby is latched on well, there is no pain.  In fact, the entire areola and nipple goes past his tongue and down his throat.  There is nothing to feel pain about.  Try this experiment.  Cup your breast in your hand and put your fingers on the boarder of your areola (that is the line where your breast changes color to form the circle of your “nipple”), now, pinch down a bit to compress the tissue.  There should be no pain. Now, slide your fingers down to your nipple and pinch there.  You should notice a significant difference.  Why?  Because the breast and areola is a protected with fat tissue, but the nipple is not.  When your baby latches well, he goes beyond the unprotected nipple to take the entire areola in his mouth.  This does two things.  First, it protects mom from sore nipples.  But even more important, it will ensure proper flow of milk to the baby.  Think of your nipples as a small bunch of straws that carry milk (which is what they are).  Now, take that bunch of straws and pinch them and try to drink from them.  What happens?  Nothing.  You can’t drink out of a pinched straw, and neither can your baby.  When your baby has a shallow latch, he pinches the tubes that brings the milk down and that makes it harder for him to get milk out.  He will go to the breast and suck, sometimes hard, fiercely even, but he won’t get much out.  Eventually, he will either get tired, or he will get a satiety signal (remember, it takes 20 minutes between first bite and full tummy signal for grown-ups and babies alike) and will come off the breast.  However, since he didn’t have a good latch, he didn’t get as much milk as he wanted/needed and will soon wake up and want to eat again. 

So your baby may be latching poorly, which leads to painful nipples and frequent feeds.  Try to make sure he has a big open mouth before he latches.  When he latches, if you feel a pinch or some tenderness, pull him close to the breast and pull down on his chin to encourage the mouth to open, the tongue will drop down and then out to cup the areola.  If it doesn’t get better in a few sucks, try it again (up to 3 times).  If that doesn’t work, take him off and try again.  Let’s see how that works, write back if there are still problems. 

Heather writes:

“My son is about to hit seven months and I've noticed lately that my milk production has decreased and I'm having a really hard time pumping, which is made worse because being in the army I only get two twenty minute breaks to pump per day. Any advice?”

Heather, I remember talking to you several months ago.  Congratulations on such a successful breastfeeding journey.  You are a rock star!!  Breastfeeding for seven months while on active duty is impressive.  If you haven’t already, I suggest you go check out “Breastfeeding in Combat Boots” a page dedicated to breastfeeding while on active duty. 

Now, to turn to your question, when the baby begins to take in solid foods, his need for breastmilk begins to decrease.  Studies have demonstrated that infant breastmilk intake drops when solids begin, and that is just logical, we can only eat so much in a day.  There is also a decrease in prolactin levels that really kicks into high gear at about six months.  While prolactin doesn’t “make milk” it allows it to be made.  But that doesn’t mean that you should stop synthesizing milk when your baby hits six months old either.

The first thing to ask is “what has changed?”  Have you started contraception (does it have estrogen?).  The questions on contraception and breastfeeding haven’t been fully answered.  There are women who are sensitive to estrogen, even 6-12 months out from breastfeeding.  Some may even struggle with progesterone only (like Depo-provera), even this far out from birth.  Have you started to have a menstrual cycle?  Menstrual cycles don’t impact breastfeeding, but it is a sign that your body is returning to its more normal state.  Ask yourself how often your baby is nursing while at home, and how much he is taking while in daycare?  Maybe you are overestimating how much you need?  Finally, and this is one that gets a lot of people, check your pump.  Believe it or not, batteries die, and so do pumps.  Pumps, even really expensive pumps are not meant to last forever, they are designed to work for about one year of daily use.  If your pump is second hand (who who buys pumps new these days?), it may be at the end of its life expectancy.  It may be time to buy a new pump (another second hand pump should tide you over). 

If everything else is the same, and your baby still needs the amount of milk you were giving him at four months, then I would fall back on the basics of pumping and milk supply.  Supply and demand is a law in breastfeeding.  The more you empty the breasts, the more milk they will make to replace it.  Spend a couple of days (perhaps over a weekend) where you pump while nursing with every feed.  After the feeding, double pump for about 10 more minutes.  This double stimulation will signal to your body that you need more than you may be making right now, and may kick production back into high gear.  The average mother’s breasts are very responsive to infant demands and will compensate for whatever the baby desires.  Give it a shot.

Finally, a little about work.  Two breaks during the day is tough, the Army certainly doesn’t make it easy on breastfeeding mothers, particularly after six months.  BFICB has some good resources for you to try, but in brief, talk about it with your boss.  Ask for one more pumping session.  You should be allowed to pump at least as often as your co-workers are allowed to smoke.  Suggest that you get a break every time one of them goes outside for a smoke.  I tend to think that even NCO’s can be reasonable when asked in the right way.  Try to ask “What do I have to do to get one more pumping break worked into my schedule?”  Come in a little early?  Stay a few minutes later?  Volunteer for a detail?  It may not be fair, but “fair” isn’t a concept found in nature.  You may have to work a little harder for what you really want.

 

And last but not least, my friend asked a follow up question about learning to pump and the law of supply and demand.

It is true that giving the baby something besides breast milk will decrease milk supply.  The lactocyte is on autocrine control after the first couple of months and synthesizes milk based on a supply and demand system.  So if you don't empty it, it will not need to replace as much, and if you repeatedly fail to empty it, the baseline function will decrease.  So there is something to be said for emptying the breast as often as possible to maintain breast function.  Where I differ from most lactation folks is that I don't believe the lactocyte is incredibly sensitive.  I think the lactocyte wants to make milk and will if you just give it the right stimulus.  There are women who could not get pregnant but are still able to nurse their adopted children.  As a woman who has delivered and breast fed there is no reason to suspect your breasts will suddenly fail you.  Of course, fear of inadequate milk supply is the number one reason for prematurely stopping.  But the actual risk of “sudden onset, idiopathic agalactia” (AKA – My breasts just stopped making milk) is less than 3% or women. 

You asked about “mother’s milk tea”, it does seem to help with putting more milk out, and we don't really know why.  It does have fenugreek, which is a galactogue, but it has not been shown to work much better than placebo in studies (I think the problem is the instruments they use to measure are measuring the wrong thing).  Mothers and doctors seem to see every complaint as a cry for food, this is re-enforced by the fact that the fussy baby calms down when you put him to the breast or give him a bottle.  I have never been convinced that a fussy baby is automatically a hungry baby.  Sucking is not only for food, it is also comfort.  If baby has a headache, sucking will make him feel better, and the milk is just a bonus.  When I have a woman who thinks she isn’t making enough, I start by asking how she knows that her breasts are failing her?  Usually (almost always) it can be attributed to a misunderstanding between mom and baby. 

As for pumping, when women develop cisterns (like cows and goats) I will put my faith in a milk machine.  The human milk ejection reflex (let down reflex) is a complicated neuropsychological process the requires several planets to line up just right, and sitting in your office plugged in to a cold impersonal pump, trying to force your breasts to "make milk" just isn't conducive to signaling the milk ejection reflex.  I hinted yesterday that the best way to pump is to put the baby on one side and pump the other.  Try that for a week and see what happens. You will probably be amazed at how much comes out while she is nursing.  That is my first recommendation for increasing supply.  The second is to remember that this is a mental game.  You have to be in the right frame of mind to pump.  If you don't have the baby around, take her blanket (it smells like her) and drape it over your breasts while pumping.  Not only will this give you the Pavlovian stimulus of a baby at the breast, it will also keep you from staring at the pump.  Relax, think about your baby, breathe in her smell and just let go of your worries and you will get better and better.  Pumping is a learned skill, not a natural ability.  Some women never figure it out, my wife can never get more than one ounce out with a pump even though she has more than 8 years of successful breastfeeding under her belt. 

My rules for making more milk are:

1) Empty the breasts often, more often than the baby needs.  Breastfeed or pump frequently for a few days in a row.  Maybe take a weekend where you and she just spend as much time as possible, skin to skin, nursing or pumping, or both.  Studies show that while decreased emptying decreases the rate and volume of emptying, it returns to baseline within 12 hours (for short term interruptions). 

2) Relax and have faith.  This is literally what your breasts are designed to do.  You have no fear that your heart will beat, or that your kidneys will filter, why would you fear that your breasts would fail you?  The only reason humans have so much trouble with nursing is that we have the capacity for worry.  Let go and trust your body to function as designed.

3) Galactogues- they certainly can't hurt, but I'm not convinced that they are necessary for the vast majority of women.  Take the tea if it works for you, but don't worry if it doesn't. 

Grand Opening - Sage Homme's Breastfeeding blog

 For a little over a year I've had a facebook page dedicated to answering breastfeeding questions and many of those questions have turned into little articles that were far too long for facebook posts.  That problem has made me want to start a blog so that I could share my thoughts on breastfeeding.  I was reading a blog today (Biomarkers and Milk http://biomarkersandmilk.blogspot.com/ ) and while there I discovered that I could start my own blog fairly easily. So look out world, HERE I COME! I'll be playing with this medium for a while, but eventually I hope to be able to submit a new post every other week.  Until then, please feel free to share any ideas you may have about building a blog, as all of this is new to me.