Breastfeeding Solutions 1.2

The Breastfeeding Solutions version 1.2 smartphone app (now expanded and improved) is available on the App Store, Google Play, and Amazon.

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Thanks to many of you, the Breastfeeding Solutions app has been a resounding success. More than 1200 people in 18 countries have downloaded the app since it debuted at the end of October. If you have helped spread the word about this groundbreaking new breastfeeding support tool, please accept my heartfelt thanks.

Reviews of Breastfeeding Solutions

For a demo of how the Breastfeeding Solutions app works, see the review by the U.K. group Andover Breastfeeding Mums or visit my Pinterest page. More online reviews of the app are at The Badass Breastfeeder and Breastfeed Chicago. It has been gratifying to receive such positive feedback from some of my favorite breastfeeding support people:

KellyMom: "Need a great breastfeeding app? The Breastfeeding Solutions app by Nancy Mohrbacher, IBCLC, FILCA is it! I installed it as soon as it was available, and have found it to be easy to use, and full of excellent information."

Best for Babes: "It appears that Nancy Mohrbacher, IBCLC, FILCA has created the WORLD'S BEST BREASTFEEDING APP. If you don't want to waste hours googling answers to your breastfeeding issues, or reading through thousands of threads, this app is for you."

What’s New in Version 1.2

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Today—in response to suggestions from users—we launched the new and improved 1.2 version of the Breastfeeding Solutions app. Those who already have the 1.0 or 1.1 versions on their smartphone or tablet should receive notification of this update from wherever they purchased it, the App Store, Google Play, or Amazon. If you have already bought the app, there is no charge to download its 1.2 version, which features three main improvements.

A new Index. The app’s home page (above right) now features a button that takes you to its Index (left), whose purpose is to make it even quicker and easier to find what you’re looking for. Now to find a specific issue, instead of browsing through the app’s Articles section, you can use the Index to go straight there.

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The screenshot on the left shows the new Index landing page. To find your burning issue, press the button that corresponds to its first letter.

More content. As one example of new content, if you’d like to read about reflux, press the index button “R.” On the next screen (right), below each index heading are buttons with page titles that correspond to every page within the app where that topic is mentioned. Press whichever button title best meets your need.

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To learn about reflux, press the button “Reflux and the Breastfeeding Baby,” which takes you to the page below left and is new content in version 1.2. Other Index headings that lead to this same new content are “Spitting up” and “Vomiting after feedings.”

More links. To make the Solutions section of the app easier to use, more links have been added to improve navigation. The goal is to make it easy for any mother to quickly get her question answered. All of the updates in version 1.2 were designed to do just that.

Please email any feedback you’d like to share about Breastfeeding Solutions to my app-comment address: nancy@nancymohrbacher.com. The beauty of an app is that unlike a book, it’s easy to update what you already have on hand without the need to buy a new edition. If you buy the app now, you automatically receive future updates.

Click here to download the app’s updated flyer and help spread the word. Thanks in advance for sharing this new helping tool with women worldwide!

For the Caregiver of a Breastfed Baby

As some of you know, I've written a book for employed breastfeeding mothers, Working and Breastfeeding Made Simple, that's available on Amazon and through Praeclarus Press. This is its handout written for the breastfed baby's caregiver. You may also download it as a pdf HERE.  --Nancy

For the Caregiver of a Breastfed Baby

You already know that you make a difference to the breastfeeding baby in your care. But you may not know what a key role you play in helping baby’s mother meet her breastfeeding goals. Here are some of the many ways you can support her.

Avoid Overfeeding

If baby takes too much milk while mother is away, baby will be less interested in breastfeeding when they are together. Less breastfeeding puts mother’s milk supply at risk. She may also need to provide more pumped milk. Anything you can do to reduce the amount of milk mother needs to pump makes her life easier. Here are more basics.

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Know breastfeeding norms. Most breastfed babies take smaller feedings and feed more often than babies fed formula. At an average feeding, a breastfed baby older than 1 month takes 3 to 4 ounces (90 to 120 mL) of milk.

Feed when baby shows signs of hunger rather than on a schedule. Cues such as rooting and hand-to-mouth mean it’s time to feed. It is common for breastfed babies to feed more often during some parts of the day than others.

Feed slowly using paced bottle feeding. When fed slowly, baby feels full with less milk, reducing mother's need to pump. If baby is older than 6 to 7 months, she may be fed by cup. If bottle fed, expect feedings to take about 15 to 30 minutes. Here’s how paced bottle feeding works:

  • Hold baby semi-upright or upright (see photos) and tap her lips with the nipple until she opens wide.
  • Help baby latch far enough onto the nipple so her lips close on the nipple’s base rather than its shaft or tip. (Gagging means baby needs a shorter nipple.) If baby’s lips are pulled in, use your fingers to flange them out.
  • During feedings, hold the bottle nearly horizontal, so the flow isn’t too fast.
  • Build in pauses every few minutes by lowering the end of the bottle so milk runs out of the nipple. Or remove the nipple from baby’s mouth and rest it on her lower lip.
  • Repeat throughout the feeding until baby is done. Switch sides halfway through.
  • Stop when baby stops, even if there’s milk left.
  • Burp baby after feeding to bring up any air.

Encourage Breastfeeding

One key way mother keeps her milk production steady is frequent breastfeeding. You can help by encouraging her to sit down and breastfeed just before leaving baby with you and as soon as she returns. To make this easier:

  • Make comfortable seating available.
  • Offer a private area for nursing, if desired.
  • Make it clear that breastfeeding is welcome and encouraged.
  • If mother is due to arrive soon and baby seems hungry, feed just a little milk until she can breastfeed.

The more times each day a mother breastfeeds, the less milk she must pump. Breastfed babies need on average about 25 to 30 oz. (750 to 900 mL) per day. The more milk baby gets directly from mother, the less pumped milk is needed.

Store & Handle Milk with Care

You can also support mother by handling her milk with care so that little milk is discarded.  

  • Let mother know if baby regularly takes less milk than is in her containers.
  • Follow the milk storage guidelines she provides.
  • Thaw and warm milk gently and gradually, keeping heat low. Swirl the milk to mix layers. Don't shake it.

Milk can be thawed in the refrigerator or overnight. You can also thaw or warm milk in other ways.

  • Hold the container under warm running water for a few minutes.
  • Hold the container in water previously heated on the stove. Do not heat the milk directly on the burner.

If you use water to thaw or warm milk, tilt or hold the container, so the water cannot seep under the lid. Feed thawed milk right away or refrigerate it.

Do not thaw or warm milk in a microwave,which changes the milk and heats it unevenly. Even if you swirl or shake the milk afterwards, hot spots remain that can burn baby’s throat.

By supporting breastfeeding in these ways, you can provide great quality of care for the breastfed baby. And at the same time you can make life easier for mother and the entire family. 

Hanging Out

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Yesterday I took part in my first Google+ On Air Hangout, where I enjoyed the enthusiasm and thoughtful questions from the winners of our Facebook Rafflecopter contest, "Win a Hangout with Nancy." The awesome Lara Audelo, author of one of my favorite books, The Virtual Breastfeeding Culture, moderated the event and kept its pace lively. The 19-minute Hangout is now available for viewing on my YouTube channel.

During our Hangout, whose purpose was to answer questions about the Breastfeeding Solutions app, we discussed:

  • Why the App Store gave Breastfeeding Solutions a rating of 17+ (I’m sure you can guess), and how that age restriction might affect the app’s availability to younger mothers
  • What motivated me to develop the app
  • How best to contact me with suggested changes or improvements
  • Why some of the app’s buttons are pink and others are aqua
  • The importance of submitting positive reviews to Google Play and the App Store to encourage more mothers to download and use the app

It has been two weeks since the app became available for Apple and Android devices, and the response has been gratifying. More than 550 people worldwide have downloaded it, nearly 400 from the U.S., 57 from Canada, 45 from the U.K., and 33 from Ireland, as well as some in Australia, Mexico, the Netherlands, Israel, Switzerland, Norway, Sweden, Singapore, Taiwan, Hungary, Germany, Estonia, and New Zealand. Thank you all!

My hope is that breastfeeding supporters will add the app to their own devices and show it to mothers. If you’d like to know more, take a look at a step-by-step demonstration of how the app works on my Pinterest page. That page also includes a jpg of a newly designed flyer you can share with mothers (download its pdf here). Until the end of the year, to make downloading the app easier for you, I’ve reduced its price by nearly 30% to $4.99 USD.

The Breastfeeding Solutions app is not intended to replace in-person help and describes how--when needed--mothers can use the www.ilca.org website to find IBCLCs in their local area. But it can be a great first resource, as it covers many of the most common problems and questions and when it's downloaded into a smartphone, it goes with mothers everywhere. Check out the first independent review of the app, which appeared this week on the Breastfeed, Chicago website.

Thank you again to Lara Audelo, and all those who participated in yesterday’s Google+ Hangout On Air: Tova Ovits, Susan Pack, Katy Linda, Ali Kulencamp, Johanna Iwaszkowiec, and Amie Norris. And thanks to all of you who have helped make the Breastfeeding Solutions app such a resounding success! The next step is to get the word out to more mothers. Any help you can give in spreading the word would be greatly appreciated!

My New Breastfeeding Solutions App

I am thrilled to announce the release of my new Breastfeeding Solutions smartphone app for mothers and breastfeeding supporters. It is now available worldwide for Android and iPhones on Google Play and the App Store. Take advantage of its early-bird pricing to save nearly 30% through 12/31/13.

 

What Does the App Do?

Based on my book of the same name, Breastfeeding Solutions does not track feedings or diapers, like most other breastfeeding apps. It helps mothers meet their personal breastfeeding goals by providing straightforward solutions to the 30 most common breastfeeding problems.

 

This new app covers every stage of breastfeeding, from birth to weaning. To find a problem’s cause, use its interactive “Solutions” section. For answers to common concerns, browse its comprehensive “Articles” section.

 

Unlike a book, this app goes with you everywhere for easy reference. The app’s testers say it’s a great resource for those who take breastfeeding helping calls away from home.

 

What’s Included?

Breastfeeding Solutions is an alternative to the apps available to mothers from the formula and breast-pump companies. But before you can recommend this industry-free app, you’ll want to try it for yourself.

 

To make this easier, I’ve lowered the price by nearly 30%. Until December 31, its price is $4.99 US. Once downloaded, you receive any updates as they are published. The app is all-inclusive and requires no in-app purchases.

 

Enter the Contest

If you’d like to learn more about the Breastfeeding Solutions app, my friend Lara Audelo, author of The Virtual Breastfeeding Culture, will be moderating a live Q & A with me about it on Google+ Hangout. This event will take place on Wednesday, November 6 at noon Central time and will be recorded and posted at a later date on my YouTube channel. To participate, you must give permission to be recorded.

 

There is room for 8 people in this live Hangout. To choose them and 2 winners of a free copy of Breastfeeding Solutions or The Virtual Breastfeeding Culture books (book winners restricted to U.S. residents), we’re having a Rafflecopter contest. To enter, click on the blue Rafflecopter “Giveaway” tab on my and Lara’s Facebook pages or on this link.

 

Lara is available if you need help using Google+ Hangout. Best of luck!

Block Feeding Dos & Don'ts

This morning I talked with a breastfeeding mother whose story is becoming all too common. Her 1-month-old third baby was having trouble coping with her fast milk flow. At many feedings, she coughed, sputtered, and sometimes pulled off the breast crying. This mom assumed from this behavior that she had an overactive let-down (OALD) and started a strategy called “block feeding.”

What is Block Feeding?

Block feeding involves restricting baby to one breast for 3-hour or longer blocks of time before giving the other breast. It is very effective at bringing down milk production when a mother is making way too much milk. Allowing the breasts to stay full for a set period of time sends the signal to slow milk production.

Block Feeding Dos

This strategy can be a lifesaver in some cases, as oversupply (aka “hyperlactation” or “overabundant milk production”) can decrease quality of life for both mother and baby. For a mother, the drawbacks of making too much milk include regularly full and uncomfortable breasts and recurring plugged ducts. For the baby, oversupply can cause a very fast milk flow that can be hard to manage. In this case, block feeding used for no longer than 1 week can be a boon for both mother and baby.

Block Feeding Don’ts

What seems to be more and more common, though, is the assumption that any struggle with milk flow is due to OALD or oversupply, when there is usually another cause. As a result, some mothers bring down their milk production with block feeding when their supply is actually at a healthy level, leading to other problems, such as slow weight gain.

As I told the mother this morning, during the early weeks, most newborns cough and sputter during breastfeeding some of the time. It takes practice and maturity for babies to learn to coordinate sucking, swallowing, and breathing during breastfeeding. Some episodes of milk flow struggles and pulling away are completely normal and are not necessarily signs of OALD or oversupply.

How to Know If Block Feeding Will Help

The most reliable gauge of whether block feeding may be helpful is baby’s weight gain.If breastfeeding is going well, during the first 3 months, most babies gain on average about 2 lb/mo. (0.90 kg/mo.). If baby’s weight gain is double this or more, block feeding for no longer than 1 week makes sense. If baby’s weight gain isn’t this high, it is likely that block feeding will cause more problems than it solves.

Alternatives When Baby Struggles with Milk Flow

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What can you do if your baby’s weight gain is average but she is struggling with milk flow during breastfeeding? The best strategy is using feeding positions that give baby more control over flow. The most difficult feeding positions for babies from a milk-flow standpoint are those in which milk is flowing downhill into their throats, such as all those in which mothers sit upright.

In the feeding position shown at left, however, milk flows uphill into baby’s mouth, giving her more control. See this post to read more about these types of feeding positions and their advantages.

If baby continues to have consistent problems with milk flow, it's time to see a lactation professional to check for anatomy, swallowing, and breathing issues. To find a lactation consultant near you, go to this website, click on the "Find a Lactation Consultant" link, and enter your zip or postal code.

References

Caroline, G.A. & van Veldhuizen-Staas, C. G. Overabundant milk supply: An alternative way to intervene by full drainage and block feeding.International Breastfeeding Journal 2007; 2:11.

Formula Use & Breastfeeding: The Moral of the Story

Earlier this week a study appeared in Pediatrics that has the media buzzing about whether giving formula in the first few days can actually improve breastfeeding rates. Both Time magazine and the New York Times featured stories on this. Not surprisingly, the media stories (and in my opinion, the researchers themselves) missed the central point.

This study compared breastfeeding outcomes in two groups of mothers whose babies had lost enough weight shortly after birth to be considered at risk. Both groups were given lactation help. In the control group, the mothers were encouraged to exclusively breastfeed. In the intervention group, after each breastfeeding the mothers were instructed to feed their babies by syringe a tiny amount of formula supplement: 10 mL, or about one-third of an ounce. This is about how much colostrum babies consume at each breastfeeding during the first 2 days of life.

The study found that more of the mothers who gave this small amount of formula after feedings breastfed longer and more exclusively than the mothers who didn’t.

Unlike the authors and the media, I don’t interpret these results to mean that early formula can help breastfeeding. In addition to all of the valid points made by other breastfeeding supporters, what was noteworthy to me was that the mothers in the intervention group were taught to supplement their newborns with biologically appropriate feeding volumes consistent with the recommendations of the Academy of Breastfeeding Medicine.

Many parents who supplement—including I’m sure those in this study’s control group—overfeed their babies incredibly, either without realizing it or because they are unwittingly instructed to do so by health professionals. Yesterday I spoke to a mother who was told by a pediatrician to make sure her jaundiced 4-day-old took 2 oz. (60 mL) at every feeding, which is twice the size of a 4-day-old’s stomach. To accomplish this, she was pumping, adding formula to her milk, and force-feeding this massive amount to her newborn.

My take-away message from this study is that any mother who supplements her newborn (whether with expressed milk, donor milk, or formula) should learn the appropriate amount to feed so she can prevent the kind of rampant oversupplementation that undermines breastfeeding and increases later risk of obesity. Babies overfed at this magnitude breastfeed much less often and milk production suffers.

What are the long-term effects of early overfeeding? One study followed to adulthood 653 people who were formula-fed from birth. Amazingly, greater weight gain during the first 8 days of life was associated with increased incidence of overweight 20 to 30 years later.  These researchers concluded that the first 8 days may be a “critical period” during which human physiology is programmed.  This may mean that breastfed babies’ greater weight loss after birth and slower return to birth weight may help promote a healthier metabolic program, which reduces the risk of overweight and obesity during childhood and beyond. At the very least, it most certainly means that parents and health professionals should be extremely wary of overfeeding newborns. To me, that’s the real moral of the story.

References

Academy of Breastfeeding Medicine.  ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate.Breastfeed Med 2009; 4(3): 175-82

Bakalar, N. How formula can complement breastfeeding.New York Times, May 13, 2013.

Flaherman, V.J., Aby, J., Burgos, A.E., Lee, K.A., Cabana, M.D., & Newman, T. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: An RCT.Pediatrics 2013; 131(6):1059-65.

Naveed, M. et al.    An autopsy study of relationship between perinatal stomach capacity and birth weight. Indian J Gastroentero 1992;11(4):156-58.

Rochman, B. How formula could increase breastfeeding rates.Time, May 13, 2012.

Stettler, N. et al.  Weight gain in the first week of life and overweight in adulthood.Circulation 2005; 111:1897-1903.

Stuebe, A. Early, limited data for early, limited formula use. Academy of Breastfeeding blog. May 13, 2012

My New Book: Breastfeeding Solutions

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Celebrate with me the release of my new book, Breastfeeding Solutions: Quick Tips for the Most Common Nursing Challenges! The book will be in stores and its e-version will be available on Amazon on April 1, but if your order is shipped to a US address, you can receive 30% off the paperback version today at www.newharbinger.com! (If possible, please use a browser other than Internet Explorer, which appears to cause issues with the shopping cart, or through Friday you can place your order by phone between 9 am and 5 pm Pacific time at: 800-748-6273.) For the special code you need in order to receive this 30% discount, go to (and please “Like”) my professional Facebook page at www.Facebook.com/NancyMohrbacherIBCLC. This special US offer, which was originally scheduled to end on Sunday, March 24, has been extended to Wednesday, March 27.

How does Breastfeeding Solutions differ from Breastfeeding Made Simple? Its focus is on problem-solving, and this slim volume was written to simplify mothers’ lives by cutting to the chase. A quick read, it features line drawings, bulleted lists, charts, and other visuals for fast, easy access to the best and most current breastfeeding strategies. It is also organized to make it easy for a mom to skip straight to her burning issue without having to read earlier chapters first.

If you’d like a sneak peek of the book…check out this special excerpt on breastfeeding the teething baby: www.newharbinger.com/teething!

Breastfeeding Solutions will also be available on April 1 through the following distributor:

UK: On June 20, Breastfeeding Solutions will be available in the UK through the distributor Constable & Robinson. For all the info, see this link. It will also be available at www.amazon.co.uk.

The Mother's Partner and the Breastfeeding Baby

For most couples, the weeks and months after the birth of a baby are some of the most joyful and stressful times of their lives. Along with the miraculous wonder of staring into a newborn’s eyes, comes the fatigue of sleepless nights and the emotional vulnerability of changing roles and shifting relationships.

During this time of transitions, breastfeeding affects family dynamics. Although many couples breastfeed in part for the closeness it brings, they are often unprepared for the intensity of this physical link between mother and baby. Nursing can be more than feeding; for many it is also an act of intimacy. Breastfeeding hormones relax the mother and heighten her sensitivity to her child, evoking an intense desire to respond to his cries. The nursing baby experiences his mother through all five of his senses, finding security and comfort as well as milk at his mother’s breasts.

Since the mother’s partner lacks this intense physical link and natural source of comfort, what does this mean to his or her relationship with the baby? In studies, some fathers of breastfeeding babies report feelings of frustration and inadequacy because they were unable to easily comfort their babies during the mothers’ absence. When they realized their relationship with their baby was different from the mothers’, they reported feeling a sense of loss. Even so, these study fathers continued to support breastfeeding. Those who wanted to be most actively involved with their babies reassured themselves that this difference wouldn’t last forever and found other ways to be involved in their babies’ care. Rather than attempting to duplicate the breastfeeding relationship, they found they could develop their own unique relationship with their children.

For some partners, though, feelings of frustration and inadequacy cause them to back off and become even less involved in their baby’s care, leading to resentment and jealousy at their partners’ absorption with the baby. Some partners perceive the mother-baby bond as a threat.

What should a couple do if the partner begins to develop feelings of resentment or jealousy? In her book, Mothering and Fathering: The Gender Differencesin Child Rearing, Tine Thevenin writes:

The adjustment that comes with having a child takes effort and understanding. Instead of allowing misunderstandings about each other’s feelings to create a rift, I would suggest that both partners explore and acknowledge their own–and each other’s–emotional responses, while at the same time adopting an attitude of, ‘How can I be of greatest help in our relationship and our family?’

No matter how the baby is fed, the mother’s partner has an important choice to make. Will he or she feel left out and become a bystander in the baby’s care or take an active role in developing a positive relationship with the baby?

The relationship between the mother’s partner and the child is intimately linked to the emotional health of the whole family. The couple’s relationship will be affected, as well as the mother’s ability to meet her own needs. When a mother has confidence in her partner’s good relationship with their baby, she will feel freer to take the time she needs for herself. And when she sees her baby and her partner happy together, it makes her feel even better about her partner.

WHAT ABOUT BOTTLES?

Although feeding is one way to interact with a baby, many couples have found that giving bottles doesn’t guarantee closeness. Julie Stock, mother of three, discovered this when she walked in on her partner absent-mindedly feeding their firstborn a bottle with his eyes glued to the football game on television. They decided to forgo bottles with their next two children and later she came to the conclusion that during their babyhood “my partner actually felt closer to the two children who didn’t get bottles, because he had to invest more of himself and be more creative during their time together.”

If the partner will be giving bottles, such as when the mother is out for a few hours or when caring for the baby after mother goes back to work, it is best to wait until the baby is about a month old before introducing them. Some babies have difficulty going back to the breast if artificial nipples are introduced early, while they are just learning to breastfeed. Once a baby has been breastfeeding well for three to four weeks, this problem is much less likely to occur.

In the book Becoming a Father pediatrician and father of eight, Dr. William Sears writes:

I discourage supplemental bottles especially during the first month because of the risk of disturbing the breastfeeding harmony that mother and baby are working so hard to establish. Instead I encourage fathers to understand, respect, and support the uniqueness of the breastfeeding relationship….In the meantime, supplemental nourishment from dad should go to the mother.

WHAT PARTNERS CAN DO

There are many other ways a partner can develop a loving relationship with a breastfeeding baby. First, be aware that mixed feelings are normal. And if a baby obviously prefers mother and is unresponsive to the partner at first, it may feel frustrating and discouraging. But even if this happens, it is important to continue to work at the relationship. Some babies take a while to warm up to the partner’s overtures. Sensitivity and patience go a long way toward building closeness.

One way to show sensitivity to a baby is recognize and respond to her cues. Notice what happens when you talk to her. Tiny babies have a short attention span and are easily overstimulated. If she turns away, seems uninterested, pensive, or drowsy, just hold her close or try again later. Eye contact, reaching out, or smiling may mean that she’s ready to interact. Just like adults, each baby is a person with preferences. She may like some ways of touching, holding, and playing and not others. If she likes what you’re doing, keep it up and try it again another time. If she does not respond or seems upset, try something else.

In his book, Becoming a Father, Dr. Sears confesses that he didn’t learn how to be fully involved until his sixth child. His suggestions for partners with babies younger than three months (the age that many find particularly challenging) include a lot of touching and holding, which he feels helps a partner and baby “feel right” together. Some of these early activities include:

  • the “neck nestle,” in which the baby nestles her head against the front of the partner’s neck;
  • the “warm fuzzy,” in which the partner drapes the infant, skin-to-skin over his or her chest with the baby’s ear over the heartbeat
  • various holds that the partner can use to comfort baby
  • bathing together
  • wearing the baby in a carrier or sling
  • infant massage

HOW MOTHER CAN HELP

The mother’s role in encouraging a strong partner-child relationship is one that is very difficult for many new mothers to carry out. During the time when nature programs a mother to protect her baby at all costs, she needs to overcome her natural inclination to hover while the partner cares for the baby. She needs to keep quiet when she feels the urge to comment on or criticize the partner’s efforts. (Does it really matter if at first the baby’s shirt is on backwards and his diaper is a little loose?) She needs to step back and let the partner-child relationship develop without her. The more of a perfectionist the mother is, the more difficult this can be.

Ginny Rossi, a first-time mother, tells how she helped encourage her partner and son to become close:

We started off slow. During the early weeks my partner would sit next to us while we nursed, touching and caressing Marco, and afterwards he would do the burping. Eventually, after burping, Marco began to fall asleep on his dad’s chest and got used to being close to him. After some weeks of this, Marco was more willing to be comforted by his dad.

Now that Marco is eight months old, my partner takes him for a couple of hours every day, and they both look forward to their time together. Not only does it make me happy to see them enjoying each other so much, but this gives me a needed break, which helps me feel better about full-time motherhood. I am convinced that their closeness today stems from their early time together.

In this age of equal partnership between the sexes and in same-sex couples, one of the lessons of pregnancy, childbirth, and breastfeeding is that sharing an equal commitment to parenthood does not mean fulfilling the same roles. Baby stands to benefit most when mother is most fully mother and her partner takes a different role. During a breastfeeding baby’s early weeks and months this may mean that the relationship between mother and baby is more intense. But a newborn needs to develop other relationships, too, and this need grows as he matures. With partner and baby, just as with any relationship, greater investment brings greater rewards.

Is Your Formerly Nursing Baby Refusing to Breastfeed?

If your baby is younger than one year, even if she seems to be losing interest in breastfeeding, chances are she is not yet ready to wean. After all, during their first twelve months babies still physically need mother’s milk. If your baby was nursing well and suddenly refuses your breast, this may be what some call a nursing strike. Besides baby’s age, another clue that a nursing strike is not a natural weaning is that baby is unhappy about it. A nursing strike usually lasts two to four days, but it may last as long as ten days. It may take some ingenuity plus the following insights and suggestions to help a striking baby go back to breastfeeding. 

What to Do

When a baby completely refuses the breast, focus first on two things:

1.  Expressing your milk

2.  Feeding the baby

Pump as often as baby was breastfeeding. This avoids uncomfortable breast fullness and helps maintain your milk production. Ideally, if your baby isn’t nursing at all, a double electric breast pump will make this faster and easier and will be more likely to keep up your supply.

Feed your baby your milk. How you feed it depends in part on your baby’s age. A sippy cup is a good choice for a baby at least six to eight months old, as it does not satisfy baby’s sucking urge like a bottle. A younger baby can take your milk by cup, spoon, or even eyedropper.

Most mothers think first of using a bottle, but choosing a feeding method that does not satisfy your baby’s sucking urge may end the strike sooner. When a baby has no other sucking outlets, such as a bottle or pacifier, he will be more motivated to go back to the breast. If your baby has been taking a pacifier regularly, consider giving it a rest until the strike ends and he’s back to breastfeeding.

What Causes a Nursing Strike?

Why do babies who nursed well suddenly refuse the breast or begin to struggle with latching? Before choosing a strategy for overcoming a strike, see if you can determine its cause from the list below.

Physical Causes

  • Ear infection, cold, or other illness
  • Reflux disease, which makes feedings painful
  • Overabundant milk production with a fast, overwhelming flow
  • Allergy or sensitivity to a food or drug mother consumed
  • Pain when held after an injury, medical procedure, or injection
  • Mouth pain from teething, thrush, or a mouth injury
  • Reaction to a product such as deodorant, lotion, or laundry detergent

 Environmental Causes

  • Stress, upset, or overstimulation
  • Breastfeeding on a strict schedule, timed feedings, or regular interruptions
  • Baby left to cry for long periods
  • Major change in routine, like traveling, a household move, or mother returning to work
  • Yelling during breastfeeding
  • A strong negative reaction when baby bites
  • An unusually long separation

 Knowing the cause will make it easier to choose an effective strategy. For example, if an ear infection is the cause, the right medical treatment and time to recover may be the best solution.

Breast refusal is stressful, but it is almost always possible to overcome it and return to breastfeeding. The following basic approaches can reduce your stress and shorten the strike.

Strategies for Overcoming a Strike

Keep time at the breast happy. Avoid turning the breast into a battleground. If your baby fights your attempts to breastfeed, feed another way and spend lots of happy cuddle time at the breast. When your baby is near the breast, talk, laugh, play, and look into his eyes. Make time there emotionally rewarding, and make any feeding time away from the breast emotionally neutral. Hold your sleeping baby against your breast during naptimes to help shorten the strike.

Spend time touching and in skin-to-skin contact. When not feeding, hold baby with his bare torso against your skin, and stay that way as much as possible. This is soothing to both of you, and the hormones released make baby more open to breastfeeding. If needed, throw a blanket over both of you. Take a bath with your baby, and use a sling or baby carrier to keep him close.

Offer the breast while baby is drowsy or in a light sleep. Many babies accept the breast again for the first time while asleep or in a relaxed, sleepy state. Try breastfeeding while baby naps. Use feeding positions baby likes best and experiment. To make the most of your baby’s natural feeding reflexes, start in a semi-reclined position with baby tummy down on your body. Lean back, and allow baby to take naps on your breast.

Trigger immediate milk flow. Pump before offering your breast to give baby milk he doesn’t have to work for. Or first try hand-expressing a little milk onto baby’s lips. If baby goes to the breast but won’t stay there, ask a helper to drip expressed milk on the breast or in the corner of baby’s mouth with a spoon. Swallowing your milk will trigger suckling, which triggers swallowing. If baby comes off the breast, offer more expressed milk and try again.

Try breast shaping and breastfeeding in motion. Shaping the breast so that it’s easier to latch may help baby take the breast deeper and trigger active suckling. Keep in mind that some babies accept the breast only while being walked or rocked, so if baby is not responding to semi-reclined positions, it may be time to get moving.

Try breastfeeding when baby’s not ravenous. To feed well, baby needs to feel calm and relaxed rather than hungry and stressed. If baby’s agitated, calm him first. Some babies will take the breast more easily if they are not very hungry, so try feeding a little milk first, using whatever feeding method is working for you. Start with one-third to one-half of his usual feeding, just to take the edge off his hunger before offering the breast.

Make the most of times that breastfeeding is going well. When baby takes the breast, breastfeed as long as he will suckle. Offer the breast again soon, rather than waiting until he is very hungry.

If your baby takes a bottle but not the breast, try a bait-and-switch. Start by bottle-feeding in a breastfeeding position and, while baby is actively sucking and swallowing, pull out the bottle nipple and insert yours. Some babies will just keep suckling.

Use breastfeeding tools. With the guidance of a lactation professional, the following devices may help you turn the corner.

  • Silicone nipple shield.In some cases, nipple shields can help a baby transition back to the breast, especially if the strike occurred after a period of heavy bottle and pacifier use.
  • At-breast supplementer.These devices provides milk at the breast through a thin tube that attaches to a container. If slow milk flow is an issue, it may help. If not, it may not be a good choice.

If these strategies don’t work, it’s time to get skilled breastfeeding help. Find someone in your area by clicking on this link.  Your technique may need a simple tweak or you may need some breastfeeding tools or help with how to use them.

Breastfeeding is the biological norm, so nearly all breastfeeding struggles have a solution. It’s just a matter of finding it. Even if settled breastfeeding seems impossible now, with time, patience, and skilled help you can make breastfeeding work again.

The Power of Belief

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Currently, two-thirds of US mothers who intend to breastfeed exclusively for at least three months do not reach their goals. Why? The US Surgeon General’s 2011 Call to Action to Support Breastfeeding identified some of the barriers women face:

  • Lack of knowledge
  • Social norms based on bottle-feeding
  • Poor family and social support
  • Embarrassment about breastfeeding in public or social settings
  • Lactation problems
  • Employment and child care
  • Problems related to health-care services

Missing from this list is one personal factor that has been closely linked to breastfeeding duration and exclusivity: “breastfeeding self-efficacy,” or a mother’s belief that she can make breastfeeding work.

Belief Affects Actions

Scientists have found that a mother’s level of breastfeeding self-efficacy is a stronger predictor of whether she meets her goals than whether she gives her baby formula. Some areas that determine a mother’s breastfeeding self-efficacy include whether she knows when baby has finished breastfeeding and if he’s gotten enough milk, if she can help the baby latch well most of the time, if she feels satisfied about how she’s managing breastfeeding, if she breastfeeds comfortably with family members present, her ability to comfort her fussy baby, and whether she continues to breastfeed at every feeding.

Research reveals that a mother’s level of breastfeeding self-efficacy influences her in major ways:

  • whether she decides to breastfeed at all (people avoid tasks they don’t think they can accomplish),
  • the amount of effort she’s willing to devote to it,
  • how she interprets behaviors and events (whether her self-talk encourages or undermines her efforts),
  • her decisions (such as whether or not she gives formula supplements), and
  • how long she continues breastfeeding when faced with difficulties.

Women with low breastfeeding self-efficacy are likely to have little breastfeeding experience and to be more familiar with bottle-feeding. During pregnancy, they may say they will “try” breastfeeding but doubt that it will work. They may spend little or no time learning about it and feel greater stress when baby is at breast. They may worry that frequent breastfeeding—which is normal—is a sign they don’t have enough milk. They may give up quickly rather than trying to learn more or find a solution to a problem. Many begin supplementing with formula early “just in case.”

Pathways to Confidence

Breastfeeding self-efficacy is not a constant. It is a variable that can go higher or lower, depending on a mother’s experiences and actions. Research has identified four pathways to greater breastfeeding self-confidence. Using these four pathways can help mothers find the inner resources they need to reach their breastfeeding goals.

Mastering breastfeeding. The first pathway is positive personal experiences. Experienced breastfeeding mothers believe they can make breastfeeding work because they have already mastered it. Success reinforces success, which can start with small victories as they learn.  This is also referred to as “task mastery.”  

Watching other mothers breastfeed. This pathway, also known as “modeling,” can be used before a mother has much personal experience. This explains why mother-to-mother breastfeeding support increases breastfeeding duration. Time with other mothers and their thriving breastfed babies relieves doubts and proves that breastfeeding can work. New mothers may feel as though “if they can do it, so can I.” New York lactation consultant Diane Wiessinger describes how this transformation occurs:

“I remember a well-educated client, a speech pathologist with a specialty in geriatric problems. No amount of reassurance on my part gave her confidence that her baby’s squeaks and gurgles were normal. They were, after all, the very sounds about which she warned her nursing-home students. I invited her to a breastfeeding support group. The dozen or so mothers all nodded calmly when she described the sounds: “Yes, our babies do that too. Maybe it’s because they can’t clear their throats.” They showed the same calm unanimity over several other anxious questions she asked: “Yes, our babies spit up sometimes. It looks like a lot, doesn’t it? Especially on a mother-in-law!” “Yes, our babies often want to nurse within minutes of seeming full. We don’t know why. More nursing seems to work.” Afterwards, my client told me, “You know, I was going from here straight to the doctor’s. Now I think I’ll just go home and enjoy my baby.”

Encouragement and support from others.  Mothers can also find this at mother-support gatherings and through phone and online contact with supportive women. On the flip side, criticism is more effective at decreasing self-efficacy than encouragement is at boosting it. In other words, the more time mothers spend with those who discourage their efforts, the lower their confidence in breastfeeding is likely to be.

Physical comfort and positive emotions. A mother’s physical and emotional states have a major effect on her level of self-efficacy. If she is tired, in pain, stressed, or anxious, this decreases her confidence that she can meet her goals. If she feels rested, calm, happy, and comfortable, this boosts her confidence.

How can breastfeeding supporters use this information to boost breastfeeding self-efficacy in the mothers they help?

  • Before and after birth, share the knowledge and skills that make breastfeeding work
  • Help mothers reduce pain or fatigue by offering effective strategies to overcome problems
  • Encourage women to spend time with breastfeeding mothers
  • Provide support and encouragement

Avoid using fear to motivate mothers, which may decrease breastfeeding self-efficacy. Instead provide positive reinforcement, reframe self-defeating thoughts, and create opportunities to practice key skills.

Mothers with high breastfeeding self-efficacy are more likely to seek help when needed and to access available resources. They are more likely to devote time and effort to overcoming breastfeeding problems. They are also more likely to persist until they reach their goals. Widespread efforts to help more mothers achieve greater breastfeeding self-efficacy could help many more reach their breastfeeding goals.

References

Bandura, A. 1997. Self-efficacy: The Exercise of Control. New York: W. H.  Freeman and Company.

Bolton, T. et. al. 2009. Characteristics associated with longer breastfeeding duration: An analysis of a peer counseling support program. J Hum Lact, 25(1):18-27.

Bowles, B.C. 2011. Promoting breastfeeding self-efficacy: Fear appeals in breastfeeding management. Clin Lact 2 (1): 11-14.

Dennis, C-L. 2003. The Breastfeeding Self-Efficacy Scale: Psychometric assessment of the short form. JOGGN 32(6):734-744.

Dennis, C-L. 1999. Theoretical underpinnings of breastfeeding confidence: A self-efficacy framework. J Hum Lact 15(3): 195-201.

Dunn, S., Davies, B., McClearly, L., Edwards, N., & Gaboury, I. 2006. The relationship between vulnerability factors and breastfeeding outcomes. JOGNN, 35(1), 87-96.

Perrine, C.G., Scanlon, K.S., Li, R., Odom E., & Grummer-Strawn, L.  2012. Baby-friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics 130(1): 54-60.

U.S. Department of Health and Human Services. 2011. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General.

Wiessinger, D. 2002. “Last step first.” In Current Issues in Clinical Education, edited by K. Auerbach, 69-73. Sudbury: Jones and Bartlett.

How Much Milk Should You Expect to Pump?

Do you ever second-guess your milk production after pumping? Do you compare it with the volume of milk your friend or neighbor pumps? Do you compare it with the milk you pumped for a previous baby? Before you start to worry, you first need to know how much pumped milk is average. Many mothers discover—to their surprise—that when they compare their own pumping experience with the norm, they’re doing just fine. Take a deep breath and read on.

Expect Less Milk in the Early Weeks

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If the first month of exclusive breastfeeding is going well, your milk production dramatically increases from about one ounce (30 mL) on Day 1 to a peak of about 30 ounces (900 mL) per baby around Day 40.1 Draining your breasts well and often naturally boosts your milk during these early weeks. But at first, while your milk production is ramping up, expect to pump less milk than you will later. If you pumped more milk for a previous child, you may be thinking back to a time when your milk production was already at its peak rather than during the early weeks while it was still building.

Practice Makes Perfect

What should you expect when you begin pumping? First know it takes time and practice to train your body to respond to your pump like it does to your baby. At first you will probably be able to pump small amounts, and this will gradually increase as time goes on.Don’t assume (as many do) that what you pump is a gauge of your milk production. That is rarely the case, especially the first few times you pump. It takes time to become proficient at pumping.  Even with good milk production and a good-quality pump, some mothers find pumping tricky at first.

Factors That Affect Milk Yield

After you’ve had some practice using your pump and it’s working well, the following factors can affect your milk yield:

  • Your baby’s age
  • Whether or not you’re exclusively breastfeeding
  • Time elapsed since your last breastfeeding or pumping
  • Time of day
  • Your emotional state
  • Your breast storage capacity
  • Your pump quality and fit

Read on for the details about each of these factors.

Your baby’s age. How much milk a baby consumes per feeding varies by age and—until one month or so—by weight. Because newborns’ stomachs are so small, during the first week most full-term babies take no more than 1 to 2 ounces (30 to 60 mL) at feedings.  After about four to five weeks, babies reach their peak feeding volume of about 3 to 4 ounces (90 to 120 mL) and peak daily milk intake of about 30 ounces per day (900 mL).

Until your baby starts eating solid foods (recommended at around six months), her feeding volume and daily milk intake will not vary by much. Although a baby gets bigger and heavier between one and six months of age, her rate of growth slows down during that time, so the amount of milk she needs stays about the same.1 (This is not true for formula-fed babies, who consume much more as they grow2 and are also at greater risk for obesity.3) When your baby starts eating solid foods, her need for milk will gradually decrease as solids take your milk’s place in her diet.3

Exclusively breastfeeding? An exclusively breastfeeding baby receives only mother’s milk (no other liquids or solids) primarily at the breast and is gaining weight well. A mother giving formula regularly will express less milk than an exclusively breastfeeding mother, because her milk production will be lower. If you’re giving formula and your baby is between one and six months old, you can calculate how much milk you should expect to pump at a session by determining what percentage of your baby’s total daily intake is at the breast. To do this, subtract from 30 ounces (900 mL) the amount of formula your baby receives each day. For example, if you’re giving 15 ounces (450 mL) of formula each day, this is half of 30 ounces (900 mL), so you should expect to pump about half of what an exclusively breastfeeding mother would pump.

Time elapsed since your last milk removal. On average, after an exclusively breastfeeding mother has practiced with her pump and it’s working well for her, she can expect to pump:

  • About half a feeding if she is pumping between regular feedings (after about one month, this would be about 1.5 to 2 ounces (45-60 mL)
  • A full feeding if she is pumping for a missed feeding (after one month, this would be about 3 to 4 ounces (90-120 mL)

Time of day. Most women pump more milk in the morning than later in the day. That’s because milk production varies over the course of the day. To get the milk they need, many babies respond to this by simply breastfeeding more often when milk production is slower, usually in the afternoon and evening. A good time to pump milk to store is usually thirty to sixty minutes after the first morning nursing.  Most mothers will pump more milk then than at other times. If you’re an exception to this rule of thumb, pump when you get the best results. No matter when you pump, you can pump on one side while nursing on the other to take advantage of the baby-induced let-down. You can offer the other breast to the baby even after you pump and baby will get more milk. 

Your emotional state. If you feel upset, stressed, or angry when you sit down to pump, this releases adrenaline into your bloodstream, which inhibits your milk flow. If you’re feeling negative and aren’t pumping as much milk as usual, take a break and pump later, when you’re feeling calmer and more relaxed.

Your breast storage capacity. This is the maximum amount of milk available in your breasts during the time of day when your breasts are at their fullest. Storage capacity is based on the amount of room in your milk-making glands, not breast size. It varies among mothers and in the same mother from baby to baby.5 As one article describes, your largest pumping can provide a clue to whether your storage capacity is large, average or small.6  Mothers with a larger storage capacity usually pump more milk at a session than mothers with a smaller storage capacity. If you’re exclusively breastfeeding and pumping for a missed breastfeeding, a milk yield (from both breasts) of much more than about 4 ounces (120 mL) may indicate a larger-than-average storage capacity. On the other hand, if you never pump more than 3 ounces (90 mL), even when it has been many hours since your last milk removal, your storage capacity may be smaller-than-average.

What matters to your baby is not how much she gets at each feeding, but how much milk she receives over a 24-hour day. Breast storage capacity explains many of the differences in breastfeeding patterns and pump yields that are common among mothers.7

Your pump quality and fit.For most mothers, automatic double pumps that generate 40 to 60 suction-and-release cycles per minute are most effective at expressing milk.

Getting a good pump fit is important, because your fit affects your comfort and milk flow. Pump fit is not about breast size; it’s about nipple size. It refers to how well your nipples fit into the pump opening or “nipple tunnel” that your nipple is pulled into during pumping. If the nipple tunnel squeezes your nipple during pumping, this reduces your milk flow and you pump less milk. Also, either a too-large or too-small nipple tunnel can cause discomfort during pumping. Small-breasted women can have large nipples and large-breasted women can have small nipples. Also, because few women are completely symmetrical, you may need one size nipple tunnel for one breast and another size for the other.

You know you have a good pump fit if you see some (but not too much) space around your nipples as they move in and out of the nipple tunnel. If your nipple rubs along the tunnel’s sides, it is too small. It can also be too large. Ideally, you want no more than about a quarter inch (6 mm) of the dark circle around your nipple (areola) pulled into the tunnel during pumping. If too much is pulled in, this can cause rubbing and soreness. You’ll know you need a different size nipple tunnel if you feel discomfort during pumping even when your pump suction is near its lowest setting.

What About Pump Suction?

Mothers often assume that stronger pump suction yields more milk, but this is not true. Too-strong suction causes discomfort, which can inhibit milk flow. The best suction setting is the highest that’s truly comfortable and no higher. This ideal setting will vary from mother to mother and may be anywhere on the pump’s control dial. Some mothers actually pump the most milk near the minimum setting.

Hands-on Pumping

Hands-on pumping is one evidence-based strategy to increase milk yield while pumping.  Click here for a post describing this effective technique.

Worries are a normal part of new motherhood, but you can make milk expression a much more pleasant experience by learning what to expect. For many mothers, pumping is a key aspect of meeting their breastfeeding goals.  A little knowledge can go a long way in making this goal a reality.

References

1 Butte, N.F., Lopez-Alarcon, & Garza, C.  (2002). Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant During the First Six Months of Life. Geneva, Switzerland, World Health Organization.  

2 Heinig, M.J. et al. (1993). Energy and protein intakes of breast-fed and formula-fed infants during the first year of life and their association with growth velocity: the DARLING studyAmerican Journal of Clinical Nutrition,  58, 152-61. 

3 Dewey, K.G. (2009). Infant feeding and growth. Advances in Experimental Medicine and Biology, 639, 57-66. 

4 Islam, M.M, Peerson, J.M., Ahmed, T., Dewey, K.G., & Brown, K.H. (2006).  Effects of varied energy density of complementary goods on breast-milk intakes and total energy consumption by healthy, breastfed Bangladeshi childrenAmerican Journal of Clinical Nutrition, 83(4), 851-858. 

5 Kent, J. C. (2007). How breastfeeding works. J Midwifery Womens Health, 52(6), 564-570. 

6 Mohrbacher, N. (2011). The magic number and long-term milk production.Clinical Lactation, 2(1), 15-18.

7 Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.     

Do Older Babies Need Night Feedings?

Has somebody told you that your baby doesn’t need to breastfeed at night past a certain age?  This age often varies by advisor. However, science tells us that in many cases, this simply isn’t true.

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Why? Babies and mothers are different and these differences affect baby’s need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond.  This is in part because if their mother has a small “breast storage capacity” and tries to sleep train her baby, her milk production will slow, along with her baby’s growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.

Degree of Breast Fullness

Two basic dynamics are major influencers of milk production. The first, “degree of breast fullness,” refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows.1 The fuller your breasts become, the stronger the signal your body receives to slow milk production.

Breast Storage Capacity

This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2 This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need.3 After baby’s first month, a mother with a large storage capacity may notice that her baby:

  • Is satisfied with one breast at most or all feedings.
  • Is finished breastfeeding much sooner than other babies (sometimes just five minutes).
  • Gains weight well on fewer feedings per day than the average eight or so.
  • Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average. 

Again, what’s important to a baby’s healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a 24-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive.4 For example, a baby whose mother’s breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day.  But to get this same 30 ounces (900 mL) of milk, if a mother’s breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day.  (This may not apply in the same way to a mother who’s pumping.)

How These Dynamics Affect Night Feedings

How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what’s important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a 24-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby’s weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn’t consider either the emotional needs of the baby or his physical need for milk.

References

1Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis, Experimental Physiology, 81(5), 861-875.

2Cregan, M. D., & Hartmann, P. E. (1999). Computerized breast measurement from conception to weaning: clinical implications. J Hum Lact, 15(2), 89-96.

3Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day, Pediatrics, 117(3), e387-395.

4Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

Why Do So Many Breastfeeding Mothers Supplement with Formula?

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According to the U.S. Centers for Disease Control and Prevention, fully one-quarter of the babies born in America in 2009 were supplemented with infant formula by two days of age, and by three months, this had increased to nearly two-thirds. A very small number of breastfed babies really do need supplements, but most do not. Why then do so many mothers planning to exclusively breastfeed supplement their babies with formula? A recent study provided some revealing answers. 

In this study, 97 English- and Spanish-speaking low-income mothers participating in a U.S. government Women, Infants & Children (WIC) food subsidy program took part in 12 focus groups. The conversations in these focus groups were recorded to allow the researchers to analyze the mothers’ responses and better understand their motivations.  

After analysis, the researchers concluded that these mothers supplemented with formula during their hospital stay primarily because they were unfamiliar with infant and breastfeeding norms and they misinterpreted their babies’ behaviors. In other words, they considered formula the solution to imaginary problems. For example, many mothers did not realize that newborns woke to feed so often and thought that giving formula would give them more rest. 

“I think I just really wanted to sleep because every time I would fall asleep he would wake up hungry and I started to become frustrated. I felt that maybe I did not fill him, because it was every 2 hours…but now sometimes it’s still like that every 2 hours.”

The mothers also believed that their colostrum, the early milk, was not enough for their babies.  Many assumed their milk would increase at birth, and when they learned this did not happen for about 2 to 3 days, they assumed wrongly that their babies needed supplements. Others perceived comments from the hospital nurses to mean they didn't have enough milk.

The mothers assumed that latching should be easy and automatic, and when their babies had any difficulty at all taking the breast, they perceived this as “breast refusal,” thought their babies didn’t “like” breastfeeding, or saw it as a sign their baby preferred formula. When they experienced breastfeeding problems, such as sore nipples, some chose to give formula rather than requesting breastfeeding help.

On the second day of life when babies are normally wakeful and fussy, many of the mothers interpreted this typical behavior as a sign their baby needed formula. As one mother said:

“I really wanted to breastfeed him, but like I said, he was hungry all the time; he wasn’t sleeping as much because of it, so I had to switch over.”

This was true even among Latina mothers, who many believe supplement routinely because of their cultural beliefs. The researcher found that cultural beliefs were not the root cause of supplementation; the Latina mothers gave supplements for the same reasons as the non-Latina mothers.

What can be done to correct these kinds of misunderstandings? Thankfully, there’s an answer.  A research team led by Jane Heinig at University of California Davis has developed a program called Secrets of Baby Behavior that was designed to give new parents the information they need about infant and breastfeeding norms to reduce unnecessary formula supplementation and to help prevent childhood obesity caused by overfeeding. These materials, which are available to everyone, describe:

  • How to interpret baby’s cues
  • How to deal with baby’s crying 
  • Infant sleep norms

When new parents understand what’s normal, they’re less likely to interpret typical baby behaviors as indicating a need for infant formula.

The Secrets of Baby Behavior blog provides parents with ongoing evidence-based guidance and support. See its explanation of why newborns usually become fussy on the second day of life  (this is true no matter how they’re fed) and its four-part series on infant sleep

For the full California Baby Behavior program implemented by California WIC, including training materials, click here.

Thank you Dr. Heinig and the team at UC Davis for these outstanding resources for breastfeeding families!

Reference

DaMota, K., Banuelos, J., Goldbronn, J., Vera-Beccera, L.E., & Heinig, MJ. (2012). Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women. Journal of Human Lactation, 29(4):476-482. doi: 10.1177/0890334412445299. Epub 2012 May 24.

Diaper Output & Milk Intake in the Early Weeks

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Are counting wet and dirty diapers a reliable indication of whether a breastfed baby is getting enough milk? During the first six weeks of life, parents are often encouraged to track daily diaper output (number of wet and dirty diapers per day), but is this an accurate gauge? Science has taken a close look and the results may surprise you.

During the first day or two of life, breastfed babies receiving colostrum typically have one to two wet diapers and stools per day. After that, some health organizations suggest breastfeeding parents track daily diaper output to estimate milk intake. According to the International Lactation Consultant Association, signs of effective breastfeeding are at least three stools per day after Day 1 and at least six wet diapers per day by Day 4. The Academy of Breastfeeding Medicine considers indicators of adequate mother’s milk intake to be yellow stools by Day 5 and three to four stools per day by the fourth day of life.

Two U.S. studies examined whether diaper output accurately reflects adequate milk intake. Both found that there was much room for error. One study of 73 exclusively breastfeeding mother-baby couples monitored the babies’ weight loss and gain, breastfeeding patterns, and diaper output for the first 14 days. The researchers found that more stools during the first 5 days were associated with positive infant outcomes. More stools during the first 14 days were associated with the lowest weight loss and early transition to yellow stools. (Mean number of stools per day was four, but some babies had as many as eight.) The first day of yellow stools was a significant predictor of percentage of weight loss (the earlier the babies’ stools turned yellow, the less weight was lost). The average number of daily stools was not an accurate predictor of initial weight loss, but the more stools passed during the entire 14-day study period, the earlier birth weight was regained. 

Because some newborns breastfed ineffectively, number of daily feedings at the breast were not related to initial weight loss, start of weight gain, regaining of birth weight, or weight at Day 14. (Mean number of daily feedings at the breast was 8.5, with a range of 6 to 11.) In fact, the researchers considered unusually frequent feeding with low stool output a red flag to check baby’s weight, as the study baby who breastfed the most times per day had the poorest weight outcomes. They found that frequent feedings with good stool output was a sign of effective breastfeeding, but frequent feedings without much stooling should be considered a red flag of breastfeeding ineffectiveness.

The second U.S. study followed 242 exclusively breastfeeding mother-baby couples, also for the first 14 days of life. These researchers found that “diaper output measures, when applied in the home setting, show too much overlap between infants with adequate versus inadequate breast milk intake to serve as stand-alone indicators of breastfeeding adequacy.” The most reliable predictor of poor milk intake was fewer than four stools on Day 4, but only when paired with the mothers’ perception that their milk had not yet increased. But even when both of these criteria were true, there were many false positives, meaning that many of these babies’ weight was in the normal range.

So at best, diaper output can be considered a rough indicator of milk intake. While it can be helpful to track diaper output on a daily basis between regular checkups, diaper output alone cannot substitute for an accurate weight and other indicators of good milk intake, such as alertness, responsiveness, and growth in length and head circumference.

In its 2012 policy statement, the American Academy of Pediatrics recommends that “All breastfeeding newborn infants should be seen by a pediatrician at three to five days of age, which is within 48 to 72 hours after discharge from the hospital.” That early checkup can identify babies at risk of low milk intake. Most newborns lose weight after birth. In the womb, they float in amniotic fluid for nine months, becoming “waterlogged,” and after birth, these excess fluids are shed. On average, breastfed babies lose about 5% to 7% of their birth weight, with the lowest weight occurring on about Day 3 or 4. If baby has lost more weight than this, make sure the scale used was recently calibrated.

Regarding diaper output, it’s important to know, too, that stooling patterns change over time. Four stools per day are average during the early weeks, but after six weeks of age stooling frequency often decreases, sometimes dramatically. Some breastfed babies older than six weeks may go a week or more between stools, which is not a cause for concern from a breastfeeding perspective as long as the baby is gaining weight well.

More Mothers Helping Mothers

If you agree that more U.S. mothers need access to free, ongoing breastfeeding support, you’re not alone. Researchers have found that with mother-to-mother support, more mothers breastfeed longer, and more exclusively and fewer have postpartum depression. Unfortunately, most breastfeeding mothers do not get the help and support they need. At birth, 75% of American women breastfeed, but by 6 months only 44% breastfeed at all, and this is down to only 24% at the recommended one year.

Enter Breastfeeding USA, a nonprofit organization whose purpose is to provide free, evidence-based help and support through its national network of volunteer accredited Breastfeeding Counselors. I joined its Board of Directors last October because I feel strongly that more mother-to-mother support is needed to help women meet their breastfeeding goals. Although Breastfeeding USA currently has Breastfeeding Counselors in only 20 states, it is the fastest growing breastfeeding organization in America, and my hope is that by this time next year, it will be active in all 50 states. As it grows, more mothers will find the ongoing breastfeeding support they need. 

If—like me—you want to help expand this free network of mother-to-mother support, just click here. You’ll find a 3-minute video I created, which explains why breastfeeding is a key women’s health issue. If you decide to support this cause, U.S. donors can receive many cool perks, such as autographed books, 1-hour Skype sessions with me and—if you have twins, triplets, or more—Karen Gromada, lactation’s resident expert on breastfeeding multiples. For large donors, I’ve even offered two all-day conferences. 

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Why did I decide to help Breastfeeding USA grow? One reason is its online centralized education system, which ensures its Breastfeeding Counselors are well educated in best breastfeeding practices and counseling skills. With this preparation, they can provide consistent, evidence-based breastfeeding help that respects individual differences. And Breastfeeding USA uses only the most up-to-date resources.

I was also impressed by its flexibility. Breastfeeding USA gives its Breastfeeding Counselors the freedom to choose many ways of helping and supporting women locally, making support more accessible to more mothers. Based on the best fit for their community, they can offer breastfeeding drop-in centers, breastfeeding cafes, classes, regular meetings, online or phone help, home visits, and more.

And I appreciated its focus on breastfeeding alone, independent of parenting philosophy. Breastfeeding USA Counselors must be comfortable promoting evidence-based information (which means it may not be a good fit for those who strictly follow parenting programs based on the latest trend or one person’s opinion), but mothers of all persuasions can learn to help other mothers breastfeed, making it inclusive rather than exclusive.  (For more on the philosophy of Breastfeeding USA, see its remarkable Statement on Breastfeeding.)

Appropriately, Breastfeeding USA has chosen as its theme for World Breastfeeding Week 2012: “Planning the Future of Mother-to-Mother Support.” I believe Breastfeeding USA will be an integral part of mother-to-mother support in the years to come. Please join me in supporting this campaign, which runs through August 16.

To Pump More Milk, Use Hands-On Pumping

Would you like an effective method for pumping more milk? Until 2009, most of us assumed that when a mother used a breast pump, the pump should do all of the milk-removal work. But this changed when Jane Morton and her colleagues published a ground-breaking study in the Journal of Perinatology.The mothers in this study were pumping exclusively for premature babies in the hospital’s neonatal intensive care unit.

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For premature babies, mother’s milk is like a medicine. Any infant formula these babies receive increases their risk of serious illness, so these mothers were under a lot of pressure to pump enough milk to meet their babies’ needs.

Amazingly, when these mothers used their hands as well as their pump to express milk, they pumped an average of 48 percent more milk than the pump alone could remove. According to another study, this milk also contained twice as much fat as when mothers used only the pump. According to previous research, in most mothers exclusively pumping for premature babies, milk production falters after three to four weeks. But the mothers using this “hands-on” technique continued to increase their milk production throughout their babies’ entire first eight weeks, the entire length of the study. 

Hands-on pumping is not just for mothers with babies in special care. Any mother who pumps can benefit from it. How does it work? For a demonstration of this technique, watch the online video “How to Use Your Hands When You Pump” HERE. As a summary, follow these steps:

1. Massage both breasts.

2. Double pump, compressing your breasts as much as you can while pumping.  (Search "hands free pumping" online for devices that fit any brand of pump and allow you to double pump with both hands free.) Continue until milk flow slows to a trickle.

3. Massage your breasts again, concentrating on areas that feel full.

4. Finish by either hand expressing your milk into the pump's nipple tunnel or single pumping, whichever yields the most milk. Either way, during this step, do intensive breast compression on each breast, moving back and forth from breast to breast several times until you've drained both breasts as fully as possible.

This entire routine took the mothers in the study an average of about 25 minutes. 

These two online videos demonstrate two different hand-expression techniques that can be used as part of hands-on pumping HERE and http://ammehjelpen.no/handmelking?id=907 (scroll down for the English version).

Hands-on pumping can be used by any mother who wants to improve her pumping milk yield or boost her milk production. Drained breasts make milk faster, and hands-on pumping helps drains your breasts more fully with each pumping.

Public Breastfeeding Now a Civil Right in Seattle

My guest blogger today is Angelita Williams, who specializes in online education and offers life long learning tips in her articles on college education, lifestyle, and wellness management.  You can contact Angelita at angelita.williams7@gmail.com.

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If you read Nancy Mohrbacher's blog often, then you probably already know about the health risks of not breastfeeding. The sad part about it is, at least in terms of breastfeeding in public, it's hard to convince others of these facts. So much so, in fact, that especially in the United States, federal and state legislation has been slow to openly accept public breastfeeding as a part of life.

Huge strides were made when the Fair Labor Standards Act was amended to make it a requirement that all employers provide breastfeeding employees time and space (other than a public bathroom) to breastfeed their young children.  Forty-seven states have likewise enacted laws that either allow women to breastfeed in public or at the very least exempt them from being charged with public indecency.

While of course, these measures demonstrate that, as time goes on, our cultural values have changed to recognize the importance of breastfeeding to the health of mothers and children and to the mother-child bond. The City of Seattle, however, has taken public breastfeeding one step further—they've made it a civil right.

According to a Huffington Post article, the City of Seattle has made it specifically illegal for any individual, business, or place open to the public to tell nursing mother's to stop breastfeeding. Although the Seattle had previously had laws permitting public breastfeeding, many nursing mothers reported being harassed and told to stop.

Now the difference between making breastfeeding in public a civil right, versus merely permitting public breastfeeding is a small but groundbreaking one. When public breastfeeding is a civil right, this move specifically acknowledges that preventing or otherwise making nursing mothers feel uncomfortable is discrimination on par with discrimination based on race, age, sex, etc.

After making nursing in public a civil right, the City of Seattle can even hold persons and businesses accountable that violate this right. Of course, punishment won't necessarily mean fines or imprisonment, but after a violation offenders may need to undergo civil rights training.

Still, laws don't necessarily change people's minds, and it's a fact that some people still believe that nursing in public is indecent or inappropriate.  Many nursing mothers choose not to nurse in public  because they worry they may be discriminated against or criticized. 

What do you think should be done, beyond laws and education, to change social mores?

Introducing the BAMS Pocket Guide

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I’m delighted to announce the debut of my latest book for lactation professionals, Breastfeeding Answers Made Simple:  A Pocket Guide for Helping Mothers,or BAMS Pocket Guide for short.  Now at the printer, this new book is expected to be ready for shipment at the end of May.

How does this book differ from its larger cousin BAMS?  Both books contain the most current information and strategies you need to help mothers with a vast array of common and unusual breastfeeding challenges.  But to make this companion volume portable enough to fit easily into your pocket or tote, I’ve removed the thousands of research citations and often lengthy explanations for these strategies. Its main purpose is to provide quick and portable answers to the questions: “What do I need to remember in this situation?” and “What should I try next?”

Its retail price is $37.95, and bulk discounts are available.  You can see its quantity prices and place orders at Hale Publishing’s website:  http://www.ibreastfeeding.com/catalog/p302/BAMS:-A-Pocket-Guide-for-Helping-Mothers/product_info.html

My hope is that this up-to-date resource will provide the information you need to more effectively help mothers meet their breastfeeding goals.