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Entries in For Employed Nursing Mothers (8)

Tuesday
Dec032013

For the Caregiver of a Breastfed Baby

As some of you know, I'm currently working on a new book for employed breastfeeding mothers that will be available through Praeclarus Press this coming spring. This is a sneak preview of a handout written for the breastfed baby's caregiver. I also have it available in pdf form for download here. Choose "Share," then "Download," and log in. --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.

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. 

Tuesday
Nov272012

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

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

1Butte, 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.  

2Heinig, 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. 

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

4Islam, 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. 

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

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

7Kent, 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.     

Wednesday
Jun272012

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.

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” at:  http://newborns.stanford.edu/Breastfeeding/MaxProduction.html. 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:  http://newborns.stanford.edu/Breastfeeding/HandExpression.html 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.

 

Monday
Aug302010

Ouch! What If Pumping Hurts?

Some moms assume pumping should be painful.  Not so!  “No pain, no gain” does not apply here.  Painful pumping means something needs to be adjusted. 

Pump Suction Set Too High.  The highest suction setting does not always pump the most milk. In fact, too-high suction can actually slow your milk flow.  Set your pump at the highest suction that feels comfortable during and after pumping…and no higher. (If you’re gritting your teeth, it’s too high!)

Pumping milk is not like sucking a drink through a straw. With a straw, the stronger you suck, the more liquid you get. When pumping, most milk comes only when a let-down, or milk release, happens. Without a milk release, most milk stays in the breast.

What is a milk release?  Hormones cause muscles in the breast to squeeze and milk ducts to widen, pushing the milk out. When this happens, some mothers feel tingling. Others feel nothing.  A milk release can happen with a touch at the breast, hearing a baby cry, or even by thinking about your baby. Feelings of anger or upset can block milk release.

While breastfeeding, most mothers have three or four milk releases, often without knowing it. To get more milk with your pump, you need more milk releases, not stronger suction.  To see my tearsheet on how to trigger more milk releases, click here.

Flange Fit Issues.  Many mothers pump comfortably with the standard flange that comes with their pump. But if pumping hurts even on low suction, you most likely need another size. If the standard flange is too small or too large, a better-fitting flange will feel more comfortable and may also pump more milk.

To check your flange fit, watch your nipple during pumping. If you see a little space all around your nipple as it’s drawn into the flange’s nipple tunnel, you have a good fit. If your nipple rubs against its sides, the flange is too small (click here to see fit drawings).  If too much of the dark area around the nipple is pulled in or the nipple bounces in and out of the tunnel, it is too large. 

Two pump companies, Ameda and Medela, offer many flange sizes with their pumps, so you can go larger or smaller as needed.  Other companies may not.  Nipple size changes with birth, breastfeeding, and pumping, so the pump flange that fit you well when you started pumping may not as you pump more.  For that reason, it’s a good idea to recheck your flange fit from time to time.

Breast or Nipple Issues can also cause pain during pumping.  If your pain is not due to too-high suction or too-small or too-large flanges, it is time to consider these questions.  Do you have nipple trauma?  If you had nipple trauma in the past, could you have a bacterial infection of the nipple?  Do you have an overgrowth of yeast (also known as thrush or candida)?  Is mastitis a possibility?  Does your nipple turn white, red, or blue after pumping?  If so, see your lactation consultant or other health-care provider to rule out Raynaud’s Phenomenon and other causes related to breast and nipple health.   Thankfully, in nearly all cases, pain during pumping is a solvable problem. 

 

Saturday
Aug212010

More on the 'Magic Number' (Part 2)

In response to the previous post, "The 'Magic Number' and Long-Term Milk Production," a reader of this blog wrote: “I have a 6-week-old and just returned to work. I pump once every 3 hours and am pumping more than enough milk for my baby. But I am fearful of pumping less. Given my son’s eating routine is still getting established and will likely change still, how do I determine my ‘magic number?’”

I suggest you begin by thinking back to your maternity leave, assuming you were breastfeeding exclusively and your baby was thriving.  On average, how many times every 24 hours did your baby breastfeed?  As a starting point, consider this your “magic number.”  For example, if the answer is 8 (which seems to be average), assume that to keep your milk production steady long-term you will need to continue to drain your breasts well at least 8 times each day.  If you’re pumping 3 times each workday, this means you’ll need to breastfeed 5 times when you and your baby are together.  (This will be much easier if 2 of these breastfeedings include one just before leaving your baby for work and another as soon as you and your baby are reunited again.)

Another factor that can affect milk production is the longest stretch between breast drainings (breastfeedings or pumpings).  Ideally, to keep milk production stable, do not regularly allow your breasts to become uncomfortably full, as that gives your body the signal to slow milk production.  If your baby sleeps for long stretches at night, I usually suggest going no longer than about 8 hours between breast drainings.  Despite the social pressure for your baby to sleep through the night as young as possible, for most mothers it is easier to keep long-term milk production stable if they continue to breastfeed at night. 

So don’t just focus on your pumpings at work.  Also keep your eye on the number of breastfeedings outside your work hours.  As I mentioned in a previous post, many of the employed breastfeeding mothers I talk to pump often enough at work, but as the months pass, the number of breastfeedings outside of work gradually decreases.  It’s not just how many times you pump at work that determines your milk production.  More important is the number of breast drainings every 24 hours and how this total compares to your “magic number.”