Breastfeeding Information

Library of Breastfeeding Articles

The following articles may be of interest to mothers and those who support them. This is just the beginning of an extensive online library which will grow over time as the organization grows. Our goal is to provide evidence-based information and support: What Does Evidence-Based Mean? Each article is well researched and contains up-to-date information. An Editorial Review Board ensures the quality of the articles. Our website and these articles are brought to you by the generous donations and memberships of others in communities across the USA. Please consider making a contribution or joining Breastfeeding USA today.

Preparing to Breastfeed

Do I Need to Buy Special Clothes to Breastfeed?

For Teen Mothers: What Breastfeeding Is Like in the First Days

Breastfeeding Aids

Nipple Shield: Friend or Foe?

Nursing Pillows: Who Needs Them?

Phone Apps for Breastfeeding Mothers

Just for Teen Mothers

Going Back to School and Breastfeeding!

For Teen Mothers: What Breastfeeding Is Like in the First Days

Positioning and Latch

Baby-Led Latch: How to Awaken Your Baby's Breastfeeding Instincts

Some Ins and Outs of Laid-Back Breastfeeding

Milk Production

Breastfeeding Your Adopted Baby

Losing Your Milk: What Seems Like Dwindling Milk Can Actually Be Normal Changes in Baby and You

The Magic Number and Long-Term Breastfeeding

Worries About Foremilk and Hindmilk

Infant Growth and Development

Diaper Output and Milk Intake in the Early Weeks

Should All Breastfed Babies have Above Average Weight Gains?

What About a Sleepy Baby?

What is Vitamin D?

Caring for Your Growing Baby

Exercise during the Breastfeeding Years

Nightwaking

Wearing Your Baby

When is the Best Time to Start My Baby on Foods Other Than Breastmilk?

Good Foods for Babies

Weaning: Every Mother's Journey

Thinking About Weaning?

Does Your Older Baby Still Need Night Feedings?

Night Weaning Older Babies and Toddlers: Mothers Share Their Experiences

Expressing Your Milk

Choosing a Breast Pump

Exclusive Pumping

Expressing Milk Before Birth: A Tool for Use in Special Circumstances

How Much Milk Should You Expect to Pump?

To Pump More Milk, Use Hands-on Pumping

Breast Versus Bottle: How Much Milk Should Baby Take?

Facts Every Employed Breastfeeding Mother Needs to Know

Hand Expression

Special Breastfeeding Circumstances

Breastfeeding Twins and More

Tandem Breastfeeding

Hiding in Plain Sight: Postpartum Depression

Breastfeeding a Baby with a Cleft Lip and or Palate - The Red Carpet Treatment

Blebs: Teeny Tiny Meanies

Breastfeeding Through Colds and Flu

Maternal Autoimmune Disorders and Breastfeeding

Expressing Milk Before Birth: A Tool for Use in Special Circumstances

Tell Me About Tongue Ties!

Family and Community

Understanding Your Fertility while Breastfeeding

Breastfeeding is Earth-Friendly

Nursing in Public: What US Mothers Faced from Colonial Times Until Today

An Open Letter to Partners

Disaster Preparedness: Breastfeeding Resources

Milk Sharing: Formal and Informal

We extend sincere appreciation to all the authors that have donated articles to Breastfeeding USA.

Breastfeeding Twins and More

There it is: one beautiful beating heart on the ultrasound screen… and then you see another.  Whether you knew it was a possibility or not, the moment you discover you’re having more than one baby is life-changing.  

Preparing for the birth of your babies:

While it is true that twin pregnancies are more likely to have complications (though only slightly higher than singletons when twins have their own amniotic sac and placenta) and are statistically more likely to end in cesarean section, having twins does not mean you can’t exclusively breastfeed or have a fulfilling breastfeeding experience.

Breastfeeding is the way human babies were made to be fed, regardless of whether they shared the womb with a sibling or not.  Twins, statistically, are born earlier than singletons, and premature babies are even more in need of the healing power of their mothers milk.  Especially if this will be your first time breastfeeding, it is very important to find evidence-based sources of information right away.  Well-meaning medical professionals, friends, and family can set “booby traps” that can prevent you from reaching your breastfeeding goals.

Get mentally prepared:

Know that for the first few weeks of their lives, feeding your babies and sleeping should be your top priorities.  Plan to do nothing but feed and love your babies, so when you do get an hour of freedom to go take a shower or close your eyes for a moment, you’ll feel refreshed instead of stressed that you only have an hour.  The first few weeks can be exhausting, so keep reminding yourself that babies change quickly--it will not be like this forever. Perspective makes a big difference in times like these.

Build a strong support network and seek out information:

Physician support and knowledge about breastfeeding can differ greatly, so dialogue with your provider and get a feeling for the level of support that you will receive. Ideally, you can find a really knowledgeable health care provider before your babies are born. You may need to seek out other sources of help in your community. In our culture, bottles are the default way to feed a baby (even if they contain human milk instead of formula), and it can be difficult to sort through the information available.  It is imperative that you have breastfeeding-knowledgeable people in your corner ready to lend you a hand if things don’t go perfectly.

Find a local Breastfeeding USA chapter and attend meetings before the birth of your babies.  Seeing other mothers breastfeed and hearing their real-life stories are two of the most important things you can do to prepare for breastfeeding, as explained in this article.  If there is no Breastfeeding USA group in your area, find another local breastfeeding group. Make sure to include your partner and support people in your learning, so they won’t unknowingly undermine your efforts.  Visit credible websites like Kellymom.com, Dr. Jack Newman’s site, or Best for Babes, and remember that the people in forums and chat groups share personal experiences and opinions which may not be evidence-based.  Take a breastfeeding class with your partner and know who to call in case you need help (Breastfeeding USA Counselor or IBCLC).

Making enough milk:

Regardless of the number of babies you are breastfeeding, establish and maintain good milk production by watching your baby and responding to your baby’s hunger cues. Let the baby determine the length of feedings. Feeding as soon as you can post birth is important for establishing a good latch and good production.  Learn more about baby-led latch here.  

Your breasts will respond and make as much milk as needed, based on the amount of milk that the babies remove.  Your baby will let you know if s/he is getting enough with the usual clues: frequent breastfeeds (at least 8-12 times in 24 hours), many wet and soiled diapers, steady weight gain. Newborns feed often; this is normal and how your body establishes milk production. If you are concerned about the frequency of feedings, especially when one baby seems to be breastfeeding a lot more often and/or longer than the other, it’s a good idea to get some help.  Here is some more information about frequent feedings.

 So many messages tell mothers of twins that they cannot make enough milk for two babies at once.  It is assumed by many medical professionals that twins will have to be supplemented, but in fact the opposite is true.  Most mothers of twins can make more than enough milk for their babies.  Trust that your body was built to do this; confidence and successful breastfeeding go hand in hand.   Surround yourself with positive messages.  Join groups online full of positive people with positive stories to share.  Read positive books, ones that tell you how to breastfeed twins, not just how to manage bottle-feeding twins.  A great book is Mothering Multiples: Breastfeeding & Caring for Twins or More by Karen Kerkhoff Gromada.  Know that your babies are no different because they came together; they are just two babies who need their mother’s milk, and your body was made to provide it.

What if one or both of my babies is in the NICU?

Some babies who stay in the NICU are not strong enough or coordinated enough to breastfeed.  This does not mean that mothers cannot provide their babies with breast milk.  The number one priority in this situation is to establish and maintain your milk production, pumping every 2-3 hours around the clock with a high quality electric breast pump.  Hospital grade pumps are available for free or rent at some hospitals. Ask for help from an International Board Certified Lactation Consultant (IBCLC) at the hospital, if one is available, and contact a Breastfeeding USA Counselor for further support.  Your babies can receive your milk via a supplemental feeding device used while breastfeeding, finger feeding, syringe, spoon, cup, or bottle.  Discuss feeding options with your baby’s care team.  Even if one or both of your babies don’t start out breastfeeding, with the proper support you can get them back to the breast when they are bigger and stronger.

Meeting the needs of each baby:

Feeding twins on cue can be very different from feeding a singleton on cue.  It’s possible that your babies will start showing hunger cues around the same time for most feedings.  If they do--great!  Some twins, especially fraternal twins, have different temperaments and different needs. One twin may need to eat every two hours, while the other is content with every three or even four!  You may hear that you have to keep them on the same schedule, but there are different ways to handle babies who seem to have naturally different rhythms.  

You can

  • feed both babies when the first one gets hungry.
  • allow both babies to follow their own patterns and feed them individually.
  • use a combination of both methods.

Some mothers find that they can follow individual cues throughout the day but need to keep both babies on the same feeding rhythm at night to minimize night wakings.  Get creative!  Whatever you decide to do, remember that you can try something new at any time.  Your babies will be growing and changing quickly in the first few months; nothing will stay the same for long.   

Tandem or individual feeding?  How to juggle breastfeeding twins:

Breastfeeding two babies feels like a juggling act, but with a little practice, creativity, and planning, it can be done with ease.

In the early days and weeks of breastfeeding, both you and your babies are learning to breastfeed.  Even if your twins are not your first breastfed babies, having twins often feels like being a new mom all over again. Breastfeeding two babies simultaneously is a wonderful skill to learn.  It saves so much time if you can nurse your babies together instead of one after another.  But like any skill, it takes practice.  If one of your babies is struggling to achieve a good latch, it’s okay to breastfeed them by themselves until you both become more skilled. Get creative with breastfeeding positions, and try them more than once or twice.  Here are a few possible positions to try.

Babies change a lot during their first few weeks and months.  When you have more than one baby reaching the milestones, it can seem much more intense, especially the relief when things suddenly get a lot easier!  Babies naturally become more efficient at breastfeeding as they get older, spending less time at the breast and eventually nursing less frequently.  Positions that were impossible to imagine using when your babies were 2 weeks old suddenly are your favorite positions when they are 6 months old.   

Two vs. one, is it that big of a difference?

It’s hard to explain to people who have never had the experience of caring for two babies simultaneously what it is like and how it is different from caring for just one.  I had a single baby, then twins, then a single baby again, and I can confidently say that breastfeeding my twins in the first few weeks was both the hardest and one of the most empowering things I’ve ever done as a parent.

Having people around who believed that breastfeeding twins was normal and possible was the only way I made it over the hurdles I encountered in the first few months.  By the time my twins were six months old and we had really gotten the hang of things, I was so incredibly thankful that I didn’t have the extra work of preparing and cleaning bottles of formula, or pumping, then preparing, and cleaning bottles of breast milk.  I was so glad that I had help and persevered through the first weeks when feeding twins.  It is a huge job no matter how you choose to do it!  Get informed; get help; and you, too, can breastfeed your babies!

Further reading:

Kellymom.com: Breastfeeding Multiples (Resources)

March of Dimes: Feeding your baby in the NICU

Booby Traps in the NICU

Choosing a Breast Pump

To Pump More Milk, Use Hands-on Pumping

Hand Expression

Baby-Led Latch: How to awaken your baby's breastfeeding instincts

Some Ins and Outs of Laid-Back Breastfeeding

Diaper Output and Milk Intake in the Early Weeks

What About a Sleepy Baby?

Help -- My Baby Won’t Nurse!  

Copyright Breastfeeding USA, May 2015. All rights reserved. No part of this article may be reproduced, copied, modified or adapted, without the prior written consent of Breastfeeding USA and the author.

What is Vitamin D?

Did you know that “Vitamin D” is not really a vitamin? It’s actually a steroid hormone produced in the body after direct exposure of the skin to ultraviolet B (UVB) radiation in sunlight. Both the vitamin D that your body produces and the vitamin D from supplements must be changed by your body several times before it can function properly. Vitamin D manages the amount of calcium in your blood and other body tissues, helps cells all over your body communicate properly, and assists your immune system in functioning effectively (Vitamin D Council, 2013).

What are the consequences of Vitamin D Deficiency?
Vitamin D deficiency may present with seizures due to abnormally low calcium levels, growth failure/failure to thrive, lethargy, irritability, and a predisposition to respiratory infections during infancy (Balasubramanian, 2011). In extreme cases, vitamin D deficiency can result in the development of rickets, a childhood bone disorder where bones soften and become prone to fractures and deformity.

If you have older children and are wondering why this wasn’t an issue when they were babies, the American Academy of Pediatrics (AAP) recently updated its vitamin D recommendations based on research that was published in April of 2010; it took a few years for the policy change to take full effect.

Nutritional Recommendations for Vitamin D
The AAP recommends supplementation of vitamin D for all infants as a preventive health measure. The AAP recommends that all children, including infants, take in 400 international units (IU) of vitamin D per day. Infants 0-12 months should not exceed 1,000 IU (25 µg) per day. Recommendations for adult intake vary depending on the organization, but usually advise an upper limit of 5000 - 10000 IU/day.

To Supplement or not?
Exposure to natural sunlight allows the human body to make its own vitamin D. The amount of the vitamin produced, however, is dependent on a variety of factors. Cynthia Good Mojab, MS, IBCLC, RLC writes, “The amount of sunlight exposure needed to prevent vitamin D deficiency depends on such factors as skin pigmentation, latitude, degree of skin exposure, season, time of day, amount of pollution, degree of use of sunscreen, altitude, weather, the vitamin D status of the lactating mother, and the current status of vitamin D stores in the infant’s body. Recommendations do and should, therefore, vary around the world, taking into account local conditions and practices.” (Mojab, 2003).

The World Health Organization recommends two hours per week of direct sunlight exposure for infants when the face is the only part of the body exposed, or 30 minutes if upper and lower extremities are exposed. But remember that the factors listed above must also be considered. Due to increases in skin cancer rates, often due to sun exposure and/or tanning beds, many healthcare professionals would prefer that unprotected sun exposure be kept to a minimum. Consequently, sunlight exposure recommendations are not hard and fast rules.

The decision on whether or not vitamin D supplementation is necessary for your child can and should be made in conjunction with your child’s health care provider. The most important thing is to make an informed decision, feeling comfortable bringing up your own questions and concerns, and sharing your informed perspective. A blood test (the 25-Hydroxy Vitamin D test) can assess your child’s existing levels of vitamin D (NIH-NLM, 2012).

Breastfeeding and Vitamin D
When breastfeeding exclusively, a mother’s pre-existing deficiency in vitamin D can result in lower levels of vitamin D in the milk she produces. If her baby gets enough sunlight, the mother’s deficiency is unlikely to be a problem for her baby. However, if her baby is not producing enough vitamin D from sunlight exposure, her milk will need to meet a larger percentage of her baby’s vitamin D needs.

The Vitamin D Council advises mothers to choose to either supplement their infant with vitamin D drops, or take a high-dose supplement of vitamin D themselves when exclusively breastfeeding (Vitamin D Council, 2013). Maternal supplementation of 6,000 IU of vitamin D per day would prevent the need for infant supplementation; the milk would likely have enough vitamin D for baby (Wagner et al., 2006). If the mother is not taking a supplement, getting a good amount of sun exposure, or taking less than 5,000 IU per day of vitamin D, her baby might need a vitamin D supplement. Mothers who choose high-dose maternal vitamin D supplementation should consider getting their vitamin D levels tested to see if supplementation is needed. Mother and baby could then be tested a few months later to track the levels.

Optimal vitamin D levels and the impact of deficiency on the body are the subjects of ongoing studies. For mothers, the prevention of rickets and other known effects of deficiency in babies is the main concern. How this is accomplished should be decided by parents making an informed choice based on available information and discussion with the mother and baby’s health care providers.

References

AAP. (2010). Vitamin D Supplementation for Infants. Retrieved on February 23, 2014 from http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Vitamin-D-Su...

Balasubramanian, S. (2011). Vitamin D deficiency in breastfed infants & the need for routine vitamin D supplementation. The Indian Journal of Medical Research, 133(3), 250–252. Retrieved on February 23, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103147/

Cannell, J. (2009). Newsletter: Vitamin D Question & Answers. Retrieved on March 3, 2015 from https://www.vitamindcouncil.org/newsletter/newsletter-vitamin-d-question...

Mojab, C. G. (2003). Frequently asked questions about Vitamin D, Sunlight, and Breastfeeding. Retrieved on February 23, 2014 from http://home.comcast.net/~ammawell/vitaminD.html#FAQ

NIH National Library of Medicine. (2012). 25-Hydroxy Vitamin D Test. Retrieved on February 23, 2014 from http://www.nlm.nih.gov/medlineplus/ency/article/003569.htm

Vitamin D Council. (2013). Vitamin D supplementation for pregnant and breastfeeding mothers. Retrieved on February 23, 2014 from http://www.vitamindcouncil.org/further-topics/vitamin-d-during-pregnancy...

Wagner, C. L., Hulsey, T. C., Fanning, D., Ebeling, M., & Hollis, B. W. (2006). High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeeding Medicine, 1(2), 59-70. Retrieved on February 23, 2014 from http://www.ncbi.nlm.nih.gov/pubmed/17661565

Copyright © Breastfeeding USA April,2015. All Rights are Reserved.

Tandem Breastfeeding

Tandem breastfeeding two children at once is something I never expected to do, and I certainly never imagined breastfeeding three (you only have two breasts after all; how would that even work?). But somehow I ended up nursing 21-month-old twins and a newborn. It sounds a little unusual to me now, too, but in the moment it was the right choice for my family. Most people don’t anticipate breastfeeding two (or more!) children at the same time, but there are some wonderful reasons to give it a try.

What is tandem breastfeeding?
Tandem breastfeeding is defined as two or more children of different ages who breastfeed at the same time. It might refer to having one child on each breast simultaneously or children who take turns breastfeeding throughout the day.

Do people really tandem breastfeed?
You might be asking yourself, “Since I’ve never heard of anyone I know tandem breastfeeding, do people really do it?” Absolutely. You may have heard of someone who has breastfed twins, but you might have never heard of someone breastfeeding children of different ages. In many cases, the older child only nurses a few times a day. S/he may not need to nurse when out in public and might be too busy when people are around, so often tandem breastfeeding occurs in the privacy and quiet of home. Because breastfeeding a toddler is beyond the current cultural norm, mothers who are breastfeeding toddlers often just don’t talk about it.

Why should I consider tandem breastfeeding?
Children who are allowed to wean themselves typically will continue nursing from 2 to 6 years. However, in the United states, only 27% of children are breastfeeding at 12 months, though the World Health Organization recommends breastfeeding AT LEAST until two years of age. Breastfeeding provides comfort, nutrition, normal development of the immune system, and social and intellectual development for as long as it continues. Breastfed toddlers may be less likely to be picky eaters because of the ever-changing flavor of breast milk!

The addition of a sibling is a huge change for a family. Breastfeeding connects children with their mothers in an emotional and physical way and also connects siblings as they “share” their mother’s milk. It’s very common for mothers to feel some guilt about spending so much time caring for their newborn when that time used to be spent caring for their older child. Breastfeeding allows mothers to reassure themselves and their older child that they still share the same bond and love as they did before.

Breastfeeding through pregnancy.
Many mothers who continue to nurse after they find they are pregnant fear they will not make enough milk or the right kind of milk for their new infants. Rest assured that the human body resets when a new baby is born and that it will produce the right kind of milk for the newest member of the family. Colostrum is very important as the first food and immune defense for the immature newborn. When the new baby is given free access to the breast, he will receive all the colostrum that he needs to get the best start in life.

But wait: If the milk changes for the newest baby, will my older child get what he or she needs from breastfeeding? Yes. Human milk is beneficial for all children of all ages. A toddler can benefit from the nutrient-dense colostrum (though you might notice some looser-than-normal stools for a bit) and the mature milk that follows. It is likely that the older breastfeeding baby or toddler is eating other foods.

Breastfeeding is also much more than nutrition. A child might continue to nurse after a mother’s milk has “dried up” for the comfort, closeness, and hormonal boost that comes from breastfeeding. Many women say they noticed a dip in their milk supply at the beginning of their pregnancy. This is due to hormonal changes, and there is no way to prevent it from happening About half of pregnant women report that their milk significantly diminished around the middle of pregnancy. For many babies this is a natural time for weaning, while others will continue to nurse. Whether or not an older sibling is nursing, the mature milk will begin to change to colostrum production during the second trimester of the pregnancy.

Many women experience discomfort, such as sore nipples, while breastfeeding during pregnancy. If this is the case for you, setting limits for your breastfeeding child is often a good compromise between nursing on demand and weaning completely.

A common concern about nursing during pregnancy deals with the ability to maintain good maternal nutrition for a growing fetus, the mother, and a breastfeeding child. Maintaining a healthy diet will always be more important during pregnancy with continued breastfeeding, but it's not significantly different from good nutrition during pregnancy itself--just more of it! Find out more about good nutrition for pregnant and breastfeeding moms.

If you have previously miscarried a pregnancy or delivered preterm, you may wonder if breastfeeding during subsequent pregnancies may increase your risk for either of these situations to happen again. Just as each child is different, so is each pregnancy. Talk with your healthcare provider about your situation. While breastfeeding can stimulate uterine contractions, so does sexual activity and to a much greater extent. If sexual intercourse isn't prohibited, then continued breastfeeding is less likely to be a concern. Ask questions of your health care provider, an International Board Certified Lactation Consultant (IBCLC), a Breastfeeding USA Counselor, and other mothers to learn as much as possible. Consider the needs of your older nursling and your own and your partner's feelings as you decide what is best for you and your unborn child

Some health care providers may not be well informed about the benefits of continuing to breastfeed through pregnancy, nor about the body’s ability to handle it. Check out the common “Booby Traps” that tandem breastfeeders may face and Myths vs. facts about pregnancy and tandem breastfeeding.

How do you juggle breastfeeding two children?
Sometimes juggling is the perfect word for breastfeeding two children! There are many different ways to approach tandem breastfeeding. How you choose to manage it will depend on your comfort level and the disposition of your children.

The most straight-forward option is to nurse your children at different times. In the early days as you and your new baby settle into a breastfeeding rhythm, you might choose this approach out of necessity, giving your newborn first dibs on the colostrum. There are ways to gently set boundaries for an older child when needed, as mentioned above.

Be prepared for a child who was previously uninterested in breastfeeding to be suddenly very interested again; this may include children who were previously weaned! When your older child is adamant about breastfeeding when the baby nurses, you might find it easier to breastfeed them at the same time. Getting creative will be important to finding positions that work for you. Usually, it’s easiest to get the littlest child settled first. Using a pillow or lying on your side can enable you to have at least one hand free to help your older child get into position. Once baby is comfortably latched and feeding, you can help your older child find a comfortable spot or (depending on the age and skill of your older child) letting them get comfortably situated all by themselves.

Possible positions include: older child and baby both straddling mom’s legs as she reclines (more information about laid-back breastfeeding here), older child in cradle position with baby lying on top in football hold, baby in cradle hold with older child kneeling or sitting next to mom, baby lying next to mom and older child sitting at mom’s back reaching over or lying on top of mom.

Here are some more tips for juggling a newborn and toddler.

Making enough milk.
Just like breastfeeding one newborn, establishing good milk production means feeding your baby on cue. The question when to feed your baby versus your older child is common. Should the baby always go first? Will the older child take all the hind milk? How can I be sure the baby is getting enough?

Your breasts will respond and make as much milk as needed, based on the amount of milk that is removed. Your baby will let you know if s/he is getting enough with the usual clues: frequent breastfeeds (at least 8-12 times in 24 hours), many wet and soiled diapers, steady weight gain. Newborns feed often; this is normal and how your body establishes milk production.

During the first few days, the baby should nurse first to ensure they get a full share of colostrum. After the first few days, you’ll need to find a breastfeeding strategy that works for you. You can alternate who gets which breast first, you can assign one breast per child (for the hour, the day or permanently), you can feed both children on both breasts as is convenient, or use a combination of all these strategies! There is no reason to be concerned about foremilk/hindmilk imbalance. Over the course of the day, your milk provides what your children need.

Is Tandem Breastfeeding For Everyone?
Not necessarily. The experience is different for every mother. It is natural for a mother to focus strongly on the needs of the new baby, and breastfeeding is the way she does this. She may feel more comfortable meeting the needs of the older child in other ways. Tandem nursing can be overwhelming at times. Some mothers set limits on the number of times that the older nursling can be at the breast. Other mothers actively encourage the older child to wean. Some mothers look forward to tandem breastfeeding and then are dismayed to find that they really don’t like it. There is no right or wrong here. Do what feels right for you and your family.

Tandem Breastfeeding Can Be Awesome!
Have you ever seen the slogan, “I make milk. What’s your superpower?” Breastfeeding one baby can be one of the most empowering and rewarding experiences of a woman’s life. For those women who choose to do so, tandem breastfeeding can expand those feelings exponentially! For me, tandem breastfeeding was just plain awesome.

Further reading:

Copyright © April 2015 Breastfeeding USA. All rights reserved.

Book review: The Science of Mother Infant Sleep: Current Findings on Bedsharing, Breastfeeding, Sleep Training, and Normal Infant Sleep

Middlemiss, W. & Kendall-Tackett, K. (Eds.). (2014).The Science of Mother-Infant Sleep: Current Findings on Bedsharing, Breastfeeding, Sleep Training, and Normal Infant Sleep. Amarillo, Texas: Praeclarus Press. 220 Pages.

The Science of Mother-Infant Sleep is a compilation of recent research on such topics as bedsharing, breastfeeding, sleep training, and SIDS. The academic tone of the book is likely better suited to health-care professionals, although parents who would like an in-depth analysis of research without a lot of opinion-based commentary would also find The Science of Mother-Infant Sleep helpful. The text provides a thorough summary of the topic, and the references that follow each chapter make it easy for the reader to investigate the topic in detail.

Each chapter of the book focuses on a specific topic related to infant sleep through a review of the recent scholarly research. It is unlike the more traditional parenting books in that it does not provide a long list of detailed instructions or procedures to follow. Instead, readers can draw conclusions from the research and determine their own plan of action.

Many parents, who are experiencing “sleep problems” with their infants and have explored all of the commercial sleep training programs, would likely find this approach to sleep research refreshing. This book excels in its approach to controversial topics such as bedsharing and sleep training. By simply reporting on the conclusions of each scientific study, the authors of The Science of Mother-Infant Sleep are able to remove all personal judgment of the decisions the reader makes. Since debates on these topics significantly contribute to the so-called “mommy wars,” the objective approach of this book is unique. The evidence-based nature ofThe Science of Mother-Infant Sleep makes it an ideal reference for health-care professionals who would like to provide the most recent scientifically based information to the parents of children in their care.

There are numerous authors of this book and all have vast experience in the fields of infant sleep and breastfeeding. Nearly all the authors have a PhD, and one of the editors is an IBCLC (International Board Certified Lactation Consultant.). They are currently working in the fields of Anthropology, Psychology, and Pharmacology, which gives them a diverse range of knowledge and experience to review research and make recommendations for parents. There are no major conflicts of interest, although the authors rely on their own research to support their claims and conclusions.

Copyright Breastfeeding USA. All rights reserved. October 2014

Hiding in Plain Sight: Postpartum Depression

OVERVIEW

Postpartum depression (PPD) is a form of depression that develops following childbirth and impacts functioning to various degrees depending on severity. Onset is usually from the first few weeks postpartum up through the first year. Postpartum depression and a condition known as the “Baby Blues” may be confused. The differences between the “Baby Blues” and PPD are the duration, intensity, and severity of the symptoms. Approximately 80% of new mothers experience what is known as the “blues” (with symptoms such as lack of sleep, exhaustion, and a roller coaster of emotions), usually due to a hormonal imbalance. However, these symptoms typically peak around two weeks and then disappear. Some mothers react more strongly than others to the changes in hormone levels, be it post-partum or even post-weaning.

Unlike the blues, postpartum depression/anxiety symptoms persist and become more severe. Mothers often report feelings of worthlessness, guilt, despair, difficulty concentrating, or other similar feelings when depressed. Appetite and sleep patterns can be disrupted and a mother coping with postpartum depression may not be able to experience pleasure or interest in the baby or her family. Anxiety symptoms often accompany the depression. She may also have a difficult time adjusting to her new life as a mother while grieving the loss of her old identity and lifestyle. Many times, the mother may feel isolated due to lack of support. In some cases, a mother may have thoughts of wanting to hurt herself or her baby. Immediate help is required in these particular situations.

RISK FACTORS

Multiple factors are believed to contribute to PPD. Medical issues, such as hormonal changes and/or a thyroid imbalance, play a role; psychosocial factors do, too. The latter may include a lack of social support, substance abuse issues, breastfeeding issues, birth defects, etc. A family history of anxiety or depression can also contribute. When doing an evaluation for postpartum depression, it is incumbent for the practitioner to assess for all of these factors. A spectrum of PPD exists (ranging from mild to severe), and if left untreated can become more severe. Approximately 20% of new mothers experience PPD, and it can affect any mother regardless of age, race, or income.

RISKS AND STIGMAS

It is unlikely that a mother will admit to depression and anxiety. Instead, she may say something like “I cry almost every day, I don’t see a way out, everything looks hopeless,” or “It feels like I am a bad mother--I should have never had this baby.” Many new mothers are ashamed or embarrassed to admit to feeling depressed and/or anxious for fear of judgment or for fear of an authoritative figure deeming her unfit and taking her baby away. Unfortunately, these fears leave the mother in a state of isolation and silence.

Postpartum depression is shrouded in myths and stigmas hindering the understanding, creation, and accessibility of resources. This is due, in large part, to the societal expectation that a new mother should be happy about her baby or that after a brief transition following the birth, she should be able to adjust fairly smoothly to her new role. The cultural expectation that motherhood will come naturally is personified and reinforced by media representations of the perky mom with her happy baby. Furthermore, the media’s portrayal of postpartum depression and other perinatal mood complications is usually negative. Media coverage is further intensified when there is a tragic outcome. For all these reasons, greater compassion, understanding, and support are crucial to break through the barriers of these stigmas. Isolation only exacerbates the depression and impairs the mother and family’s well being.

THE IMPACT OF POSTPARTUM DEPRESSION ON FAMILIES

A cycle of perpetual negative reinforcement and isolation exists which leads to a continued deterioration of coping skills and a likely increase of family conflict. Postpartum depression has a ripple effect influencing the mother’s ability to bond with her baby, as well as adversely affecting her relationship with her partner or other family members. Oftentimes, the partner feels bewildered by the mother’s symptoms, is unsure of what to do, and/or feels helpless. S/he, however well intentioned, may expect the mother to “just snap out of it,” unable to understand that what she is experiencing is out of her control. The impact of untreated postpartum depression on the child could include low birth weight, disruption of the bonding process, insecure attachments, and social/behavioral problems in the older child. Early intervention and treatment is crucial to improve the outcome of the entire family unit.

SCREENING AND TREATMENT

A mother experiencing postpartum depression needs to understand that she is not alone, it is not her fault, and (with help) she will get better. Screening for PPD is crucial for identifying risk factors as early as possible. Ideally, screening would begin during pregnancy and occur during regular intervals during the postpartum period. It is the hope that in the future every hospital and birth center will have a screening protocol in place. The Edinburgh Postnatal Depression Scale (EPDS)1 is an example of a widely used screening tool that is adaptable in many languages and is easy to administer and score. Please note that the EPDS is a screening tool only - it does not assess the severity of the symptoms, nor is it a diagnostic tool. Follow up with the clinician is necessary to make an accurate diagnosis. Also, if the mother answers anything other than a zero on question number 10 (harm-related question), an immediate referral for further assessment and intervention is mandated.

The good news is that effective treatment for postpartum depression is available. Treatment includes individual counseling, support groups (face to face or online), one-to-one peer support, medication, or a combination of these. Individual counseling provides a trusting, supportive atmosphere where the mother can open up about her experience, focus on her strengths, and work on solutions to improve coping skills. Support groups are very powerful in that the mother can identify with others experiencing similar circumstances. This is a powerful affirmation that she is not alone. Several online support groups are available, making it a cost effective option and allowing the mother to participate from home. One-to-one peer support involves individuals, such as postpartum doulas, parent mentors, or other volunteers, communicating with the mother on a regular basis.

Finally, medication may also be a very helpful option in reducing depression and anxiety symptoms, thus increasing coping skills. However, many mothers are hesitant to consider medication for fear of stigma or how it will affect them or their babies. The decision to take medication is a personal one, and the risks and benefits of medication for the mother and her baby need to be carefully considered. The mother will need to be referred to a physician for further information and a medication evaluation. Resources, such as Lactmed, are available to help mothers and physicians evaluate pharmaceutical options.

POSTPARTUM DEPRESSION AND BREASTFEEDING

Mothers with PPD may feel that this condition is a contraindication to breastfeeding. However, it may be a situation where the mother needs to understand issues such as the use of medication, getting enough sleep, and family interactions, then figure out a strategy to meld these factors with breastfeeding. The interplay of these factors may or may not impact an individual mother’s decision whether or not to begin or continue to nurse.

Mothers with PPD may ask the following:

  • “Can I breastfeed while taking a particular antidepressant/anti-anxiety medication?”
  • “How can I maximize the amount of sleep I am getting while continuing to breastfeed?”
  • “I can’t/don’t wish to continue to breastfeed...am I a bad mother?”

The bottom line is the well being of the mother and child. In her article on breastfeeding and depression, Kathleen Kendall -Tackett points out the benefits of breastfeeding in a mother experiencing PPD. 2 Lactation consultants, Breastfeeding USA Counselors, and educators can be extremely helpful and supportive in helping the mother with breastfeeding questions and issues. This support is crucial if a mother wants to continue to nurse, especially if she is having problems. In cases of severe PPD, early intervention with medical consultation is important for the health and safety of mother and baby. The risks of untreated PPD to the infant are documented.

As Katherine Stone states,
“I know some mothers who suffered from PPD that felt incredible relief when they decided to stop breastfeeding, while others found their depression worsened. The decision to breastfeed (or not) is a very personal one. It is critical to recognize that breastfeeding is more important to some mothers than it is to others (whether that is biologically, intellectually, or emotionally determined). The relationship between PPD and sleep quality is critical. Unfragmented sleep is important in helping mothers to manage and overcome PPD. But if breastfeeding is highly valued to a particular mother (and to her mental health) and if the mother is breastfeeding successfully, then the sleep advice needs to be compatible with maintaining a healthy milk supply. Bad sleep advice could cause the mother’s milk supply to plummet and unnecessarily compromise her ability to breastfeed her baby.”3

Whatever decision the mother chooses needs to be respectfully accepted without judgment.

CONCLUSION

In summary, postpartum depression is an issue that needs to brought “out of the closet.” So many new mothers experience it, yet it is an issue that is shrouded in secrecy and shame. The good news is that more attention is being focused on PPD. Increasing services for advocacy, education and resources is crucial if we are able to encourage the many mothers and families who require help to receive it without shame or fear of repercussion. The new mother needs to understand that she is not alone, not to blame, and with help will get better.

REFERENCES
1. Cox, J.L., Holden, J.M. Sagovsky R. (1997). Edinburgh Postnatal Depression Scale

2. Kendall-Tackett, K. A new paradigm of depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammation protects maternal mother health. International Journal of Breastfeeding 2007, 2:6

3. Stone, K. (2013, June 6) Sleep management, breastfeeding and postpartum depression. Postpartum Progress http://www.postpartumprogress.com/sleep-management-breastfeeding-postpar...

Copyright Breastfeeding USA. All rights reserved. August 2014

Exercise during the Breastfeeding Years

For Aimee Teslaw, making time for cardio, Pilates, yoga, biking, dog walking, swimming, and playing outdoors with her children is important for a healthy lifestyle. So is breastfeeding. Aside from the occasional plugged duct, she says exercising hasn’t negatively impacted her milk supply. Teslaw, a Breastfeeding USA member in Barrington, IL, said she isn’t a lifelong athlete but began exercising in college and continues to work out both on her own and with her children. “I love exercising as much as I love breastfeeding!” she says. “It’s all part of my personal wellness plan.”

Research shows 1,2,3,4 that moderate exercise doesn’t affect milk supply, milk composition, or baby’s growth. Lactic acid levels have been shown to increase somewhat when a mother exercises to maximum intensity, described as exhaustive exercise, but there are no known harmful effects to the baby.5,6,7,8,9 A couple of small studies10,11 found no difference in immunologic factors after moderate exercise, but they showed a decrease in immune boosting proteins after exhaustive exercise. Levels return to normal within an hour, and the impact on baby is unlikely to be significant.

Most breastfeeding mothers naturally increase their calorie intake to adjust for those expended through exercise. While some moms anecdotally report difficulty consuming enough calories to compensate for increased exercise, an Australian study12 found no impact on infant growth. Researchers examined 587 mothers and found that for their babies age 6-12 months, exercise had not decreased breastfeeding duration. At a year, exercise had no significant impact on baby’s growth. The findings applied to both women exclusively breastfeeding and those who said they did “any” amount of breastfeeding.

Breastfeeding mothers would have to reach a high level of exercise and/or diet restriction to experience a drop-off in milk production. It depends, in part, on what the mother’s body was accustomed to before lactation. That’s why mothers who are calorie-restricted, such as in famine-stricken areas of Africa, are still able to produce adequate milk, whereas the average mother in America might have problems if her calorie intake was suddenly decreased to that degree. Mothers are urged to start slowly in any new diet or exercise program, and work up to their goal over a period of time.

Mothers who are overweight or obese before or during pregnancy, may find that they actually do need a combination of exercise and calorie restriction in order to lose weight while breastfeeding. They need to start slowly and work up to a comfortable pattern of weight loss.

Exercising tips for breastfeeding mothers(from KellyMom):
For your own comfort, you may wish to nurse before exercising and wear a good, supportive bra. Some babies object to breastfeeding after mom has been sweating due to the salt on mom’s skin. You may wish to take a shower before nursing. If you regularly lift weights or do other exercise involving repetitive arm movement and you develop plugged ducts, cut back and start again more slowly. Keep yourself hydrated.

Some mothers share their stories:

I am breastfeeding my 24 month old and 5 month old. I started walking 30 minutes to an hour a day with my family or just the babies. About 2 months ago, I started going to an hour of Zumba a week to get some “me” time, and it does wonders! I am happier, refreshed, and have more energy for my kids. Before this, I never worked out, except for high school PE and sports, almost 20 years ago! I have not had a problem with my supply, but I make sure to keep up on my calorie intake and stay well hydrated.
Alissa Gomez-Dean

I do not "work out." I juggle regularly, dance 45-60 minutes a day in my living room with my kids and walk pretty much every day between 3-5 miles going to and from places by bus. Parenting activities are nowhere near the level of activity that I sustained before kids. Between clowning, performing on touring shows, city living, and never eating "real" meals, I have put on weight just because of the amount of calories I consume to maintain my milk production for tandem breastfeeding. I have no idea how my activity level affects my milk production because I don't really track feedings at this point. If I sit still long enough, some kid inevitably asks to nurse.
Christine Duenas
Staten Island NY Chapter

Around 6 months postpartum with my second child, I attempted to work out. I did a modified version of P90x. Within the first week, I dropped 9 lbs. and couldn't ever feel satisfied after eating. I couldn't keep up with the calories I needed, and my milk supply started waning. I never recovered the weight lost, and now, a year later, I am below my typical weight by 8 lbs. Prior to having children, I was an athlete in college and a very fit individual leading up to pregnancy. I have recently started working out again and am hungry constantly. My 21 month old has increased her nursing sessions from 2-3 per day to every few hours. I know this isn't typical but for me, working out has a big impact on my body while breastfeeding. Even simple workouts like Pilates and yoga wear me down.
Sarah Harding

Note: When exercise (and thus calorie expenditure) is too overwhelming with very fast weight loss, the baby may be hungry and nurse more frequently to boost supply. While this is definitely not the norm, it does occasionally happen and shows that even experienced athletes may need to resume exercise more slowly or at a lower intensity after childbirth and during lactation. Our bodies and metabolism can change with the cycle of pregnancy, birth, and lactation. Going slowly, listening to your body, and watching your baby are the best ways to ease into a healthy program.

I (along with my friend and another Breastfeeding USA member) exercise 5-6 days a week. We run 10-15 miles/week and do strength training, kick boxing, etc. I haven't had any supply problems at all.
Mandy Leonards

I am Mandy's friend and haven't noticed any major supply issues. My 17 month old still wakes 3+ times in the night to nurse and asks for breastmilk maybe 4-5 times throughout the day. I worked out while nursing with both of my babies, and I guess I notice a very, very slight decrease in production, but that is directly after a tough workout—I just feel empty (even though I know my breasts are never actually empty). The biggest thing I notice is it taking longer for my milk to let down, but since my baby is much older, I am not too concerned if she gets a couple of ounces less because she eats a ton of solids, as well. After a healthy snack and a big glass of water, I feel much less empty, and let down happens more quickly. Just my experience!
Megan Raymont

In conclusion, it seems from the research, and even from our own very small sampling of mothers’ stories, that for most moms, breastfeeding should not be seen as any kind of deterrent to a healthy exercise program. For each mother, the type and frequency of exercise may be different, but the fact is that our bodies are meant to be in motion. Healthy mothers - healthy babies. Go for it!

References

1. Daley AJ, Thomas A, Cooper H, et al. Maternal exercise and growth in breastfed infants: a meta-analysis of randomized controlled trials. Pediatrics 2012 Jul;130(1):108-14.

2. Dewey KG. Effects of maternal caloric restriction and exercise during lactation. J Nutr 1998 Feb;128:386S-389S.

3. Dewey KG, Lovelady CA, Nommsen-Rivers LA, McCrory MA, Lonnerdal B. A randomized study of the effects of aerobic exercise by lactating women on breast-milk volume and composition. N Engl J Med 1994 Feb 17;330:449-453.

4. Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proc Nutr Soc. 2011 May;70(2):181-4. Epub 2011 Feb 24.

5. Quinn TJ, Carey GB. Does exercise intensity or diet influence lactic acid accumulation in breast milk? Med Sci Sports Exerc 1999 Jan;31(1):105-10.

6. Wallace JP, Ernsthausen GI. The influence of the fullness of milk in the breast on the concentration of lactic acid in postexercise breast milk. Int Jour of Sports Med 1992;13:395-398.

7. Wallace JP, Inbar G, Ernsthausen K. Infant acceptance of post-exercise breast milk. Pediatrics 1992 Jun;89(6 Pt 2):1245-7.

8. Wallace JP, Rabin J. The concentration of lactic acid in breast milk following maximal exercise. nt J Sports Med 1991 Jun;12:328-31.

9. Wright KS, Quinn TJ, Carey GB. Infant acceptance of breast milk after maternal exercise. Pediatrics. 2002 Apr;109(4):585-9.

10. Lovelady, CA, Hunter, CP, Geigerman, C. Effect of exercise on immunologic factors in breast milk. Pediatrics 2003;111;148-152.

11. R.L. Gregory, J.P. Wallace, L.E. Gfell, J. Marks, and B.A. King, Effects of exercise on milk immunoglobulin A. Med. Sci. Sports Exer 1997; 296–1601.

12. Dada Su, Yun Zhao, Colin Binns, Jane Scott and Wendy Oddy. Breastfeeding mothers can exercise: results of a cohort study. Public Health Nutrition,2007,10, pp 1089-1093.

Copyright Breastfeeding USA 2014. All rights reserved.

Understanding Your Fertility while Breastfeeding

Introduction
As you journey into motherhood, bonding with and caring for your new baby, the thought of another pregnancy may be distant. Whether or not you want more children in the future, the time to think about your fertility is before or soon after giving birth. Considering options and determining what best meets your personal circumstances can be overwhelming. This article discusses your fertility while breastfeeding and provides links to additional online resources. It is a starting point, which we hope will inspire you to continue this important conversation with your health-care provider and/or your partner.

After birth, when will my fertility return?
Fertility often returns in stages. You may first experience menstruation without ovulation or ovulation without luteal competency (when the uterine lining can support implantation). When you are both ovulating and have luteal competency, your fertility has fully returned. Most women will not start ovulating in the first six weeks after giving birth.1 Breastfeeding typically delays the onset of ovulation.2 Depending on the intensity of breastfeeding, it can be several months or over a year before you regain your fertility. Conversely, absence of breastfeeding may cause you to start ovulating as early as three weeks after giving birth.1

Why is it important to understand your fertility?
The World Health Organization recommends that women wait 24 months after giving birth before becoming pregnant again.3 Your health improves when you have a chance to recover, physically and emotionally, from giving birth and caring for your new baby. When you are healthy, your family benefits, too. Closely spaced pregnancies increase health risks, including preterm labor and low birth weight.4 Women also space childbearing for social and financial reasons. If your first menstruation is preceded by ovulation, you may become pregnant before you are aware that you are fertile again. The possibility of getting pregnant makes it important for women to make and act on decisions about their fertility before or soon after giving birth.

How can fertility be managed?
Contraception refers to methods (and devices and practices) used to reduce the risk of pregnancy. There are many different contraceptive methods, and a little later in this article we’ll look at many of them. First, let’s discuss some of the personal considerations that may influence you as a breastfeeding mother. The following steps can guide your decision-making process:

Establish your fertility goal: For how long do you want to avoid childbearing? How important is it for you to not get pregnant right now? What would you do if you experienced an unintended pregnancy?

Determine what your breastfeeding goal and actual patterns are: How old is your baby? Are you exclusively or partially breastfeeding right now? For how long do you want to breastfeed? How important is it to you that the contraceptive method you use is compatible with breastfeeding?

Consider what fits your personal circumstances and daily routines: How does your relationship status affect your contraceptive choices? How important is ease of use? Do you need a method which is long-acting? Discreet? If you have used certain methods in the past, what did you like and dislike about them?

Respect your own conscientious convictions: What methods are compatible with your personal values and religious beliefs?

Prioritize: Of all these considerations, which ones are more important to you and your family right now?

Consult your health-care provider and/or partner before starting or stopping a contraceptive method. There may be health considerations--such as your age, any illnesses, or smoking--which affect what contraceptive methods you can safely use. Your health-care provider will help you determine your clinical eligibility and identify whether there are methods you should avoid. Your health insurance may restrict what methods are covered under your plan. Talk to your provider about all of your options. Below are some useful questions that you can ask. If you have chosen a method, your provider should also explain or demonstrate how to use it correctly.

Questions to ask your health-care provider:

  • How does this method prevent pregnancy?
  • How effective is it in preventing pregnancy?
  • How long is this method effective?
  • How do I use it correctly?
  • What are the side effects and risks of this method?
  • What evidence exists about its effect on breastfeeding?
  • Have any breastfeeding mothers in your practice had negative effects on their milk production?
  • If I experience negative effects on milk production, what do you recommend?
  • How easily reversible is the method? When do its effects wear off after I stop using it?
  • If and when I want to have another child, how quickly will my fertility return after I stop using the method?
  • Is there any medical reason why I should not use this method?
  • What does it cost? Does my insurance cover it?
  • What are comparable options?

Contraception
This section looks at how different contraceptive methods prevent pregnancy, their efficacy, and compatibility with breastfeeding. When health professionals talk about efficacy, they usually refer to ‘perfect use’ and ‘typical use.’ Perfect use means that you always use the method correctly. Typical use refers to how most people actually use the method, including incorrect and inconsistent use. Because there are many factors and barriers that influence our use of contraceptives, the average person falls under ‘typical use.’ Failure rates for both perfect and typical use are reported in percentages. The data indicates how many women out of 100, who use the method for one year, will experience an unintended pregnancy.

Lactational Amenorrhea Method (LAM):

  • Works by suppressing ovulation.2 Without an egg, pregnancy cannot happen.
  • Depends on exclusive breastfeeding and breastfeeding on cue.5
  • Is very effective in preventing pregnancy temporarily.6

For LAM to effectively reduce the risk of pregnancy, you need to meet three conditions:

  • your menses have not returned;
  • your baby is younger than six months and;
  • you are exclusively breastfeeding and not allowing long periods of time between feedings.7

The last condition means that your baby does not get supplements of foods or liquids, does not use a pacifier frequently, and does not go longer than approximately four hours during the day and six hours during the night without breastfeeding.

With perfect use, the failure rate of LAM is 0.45% for six months after birth. With typical use, it is 2%.2, 8 LAM may not be as effective for mothers who are separated from their babies and rely heavily on expressing milk, including mothers who are employed outside the home or are full-time students.9 LAM requires that you evaluate and re-evaluate your situation on an ongoing basis to make sure that the three conditions are still met. Whenever one of the conditions is no longer met, the failure rate may be increased, and an alternative contraceptive method would be recommended.5

Other natural methods:

  • Work by avoiding contact between sperm and the vagina, constantly or periodically, when you are at risk for pregnancy.
  • Are fully compatible with breastfeeding.
  • Are very to somewhat effective in preventing pregnancy.6

Abstinence means refraining from shared sexual activity that can result in pregnancy and sexually transmitted infections. To be effective abstinence needs to be practiced constantly. If you decide to have sex, another method is necessary to prevent pregnancy.

There are different fertility awareness-based methods that can help you identify when you are fertile. The symptothermal method requires you to 1) check your cervical mucus daily; 2) take your temperature each morning at the same time and before voiding, and; 3) chart your ovulation symptoms. 10 It can be used once your menstrual cycle has started and become regular again.11 During days when you are at risk for pregnancy, you can practice periodic abstinence, withdrawal, or use a barrier method (discussed below).

Withdrawal (or the ‘pull out’ method) requires your partner to completely remove the penis from the vagina before ejaculation to prevent sperm from entering the vagina. If a man ejaculates on the vulva or near the vaginal opening, sperm can still enter the vagina. After an ejaculation, small amounts of sperm may be left in the man's urethra. There is inconclusive evidence whether the amount of sperm in pre-ejaculatory fluid (precum) can cause pregnancy, and research shows that this is likely to vary greatly between individual men. While withdrawal is more effective in preventing pregnancy than unprotected sex, it is not recommended if avoiding pregnancy is critical for you.

With perfect use, natural methods have very low failure rates (constant abstinence: 0%;
symptothermal method: 0.4%; withdrawal: 4%).6 These methods are accessible to all women at no or low cost. Their main disadvantage, however, is that they are often used incorrectly and inconsistently. They require user knowledge, significant self-control, and good communication between partners. Failure rates increase exponentially with typical use: (no method: 85%; fertility awareness-based methods: 24%; withdrawal: 22%).6

Barrier methods:

  • Work by blocking sperm from passing through the cervix.11 Without sperm, pregnancy cannot happen.
  • Are fully compatible with breastfeeding.2
  • Are effective in reducing the risk of pregnancy.6

The most common barrier method is the condom. There are female and male condoms. They are relatively inexpensive and usually easy to acquire. With perfect use, the failure rate for male condoms is 2%, and for female condoms it is 5%.6 Many people use condoms incorrectly and inconsistently. With typical use, the failure rate for male condoms is 18%, and for female condoms it is 21%.6 Condoms also reduce the risk of sexually transmitted infections. They can be used simultaneously with other contraceptive methods, thus offering ‘dual protection.’ Other barrier methods, such as the cervical cap, diaphragms, and the sponge, are less effective than condoms, especially for women who have given birth. Diaphragms need to be refitted after childbirth or with large weight swings. Diaphragms and cervical caps are more effective when used in conjunction with spermicides.

Hormonal methods:

  • Work both by suppressing ovulation and making cervical mucus thicker, which blocks sperm from passing through the cervix.11, 12, 13, 14 If there is neither an egg nor sperm, fertilization cannot happen. Some of these methods also suppress growth of the uterine lining (details in listing below).11, 13
  • Are compatible with breastfeeding15 but are not recommended as the first choice for breastfeeding mothers.2, 16
  • Are very effective in preventing pregnancy.2, 6, 11, 17

Hormonal methods can be divided into different sub-categories, including short-acting and long-acting, and combined hormonal and progestin-only contraceptives. Combined hormonal methods, such as the ‘pill,’ the patch, and the vaginal ring, contain both estrogen and progestin. Estrogen may decrease milk production and negatively affect breastfeeding duration.2, 16 The World Health Organization recommends that breastfeeding mothers avoid combined hormonal contraceptives in the first six months after birth unless other methods are not available or acceptable.18 The Academy of Breastfeeding Medicine recommends alternative methods until after the baby has weaned.2

If you are breastfeeding, progestin-only methods are preferred over combined hormonal ones.2, 19 Progestin-only contraceptives include the ‘mini pill,’ the implant, injectables, and the intrauterine system (IUS). The earliest recommended use of progestin-only methods by breastfeeding women, who are clinically eligible to use them, is usually six weeks after birth, if milk production is well-established.2, 16, 19 There are anecdotal clinical reports that progestin-only contraceptives can decrease milk production, too.2, 16

The possible negative effects on milk production can sometimes be difficult or impossible to fully reverse with either combined hormonal or progestin-only methods, especially with methods that cannot be stopped quickly. A nursing mother needs to carefully consider whether to use any of the hormone-based contraceptives while the baby is dependent on breastmilk for the majority of his nutrition. The importance of pregnancy prevention versus maintaining optimal milk supply is something that only the mother can assess.

The following information is based on evidence current as of the date of publication and is not meant as an endorsement of any particular method or as being compatible with breastfeeding.

Select progestin-only contraceptives2, 6, 11, 12, 13, 14, 19

Progestin-only pill (also called the ‘mini pill’)

  • Perfect use: 0.3%
  • Typical use: 5%
  • Requires taking the pill daily and at the same time. Can be stopped at first sign of adverse effects on milk production.

Implant

  • Perfect use: 0.05%
  • Typical use: 0.05%
  • Requires no daily routine and works for three or five years depending on the brand. Like other hormonal methods, the implant suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. It may also suppress growth of the uterine lining.

Injection

  • Perfect use: 0.2%
  • Typical use: 6%
  • Should be administered every 12 weeks. It takes longer for the hormone from the injectable to leave your system compared to other hormonal methods. If it has adverse effects on breastfeeding, the method cannot be quickly reversed. It must wear off on its own.

Intra-uterine system

  • Perfect use: 0.2%
  • Typical use: 0.2%
  • Requires no daily routine and works for up to five years. The hormone is released locally in the uterus, and it typically has little to no effect on milk production. Like other hormonal methods, the IUS suppresses ovulation and makes cervical mucus thicker, which prevents fertilization. The IUS also suppresses growth of the uterine lining.

If I choose a hormonal method, will hormones in my breastmilk affect my baby?
Hormonal contraceptives have been used by breastfeeding mothers for decades without any reported adverse outcomes for their babies due to ingestion of hormones in the breastmilk.16 The level of estrogen that transfers to human milk is low. It does not exceed the level that occurs naturally when a woman ovulates.20 Natural progesterone is poorly absorbed by the infant via milk.20 Changes observed in milk composition of breastfeeding mothers who are using hormonal contraceptives are within normal variations.5

Copper-bearing intrauterine device (IUD):

  • Works by releasing copper ions, which change the chemical environment in the uterus and destroys the function of sperm before they can fertilize the egg.13
  • Is fully compatible with breastfeeding.2
  • Is very effective in preventing pregnancy.6

The copper-bearing IUD is available for breastfeeding mothers who want long-acting, reversible contraception without hormones. After the IUD is placed by a trained provider, there is no daily routine, and it can be used for at least 10 years. In the first year, the typical failure rate is 0.8%.6 Over the course of 10 years, the typical failure rate is 2%.11 The copper-bearing IUD can also be used as emergency contraception for up to five days after unprotected sex.21 When placed after unprotected sex, the copper-bearing IUD prevents fertilization and may also prevent implantation.22

Permanent methods:

  • Tubal ligation works by blocking the egg in the fallopian tube. Vasectomy works by keeping sperm out of semen.11
  • Are fully compatible with breastfeeding. Medications used during the tubal ligation procedure may temporarily affect breastfeeding.2
  • Are very effective in preventing pregnancy.6

If you are positively certain that you have completed childbearing, permanent contraceptive methods may be for you (or your partner). With tubal ligation, the fallopian tubes are surgically cut or blocked. If you want to have the procedure done immediately after childbirth, you have the right to give informed consent before giving birth.11, 23 In the first year after the procedure, the typical failure rate is 0.5%.6 Over the course of 10 years, the typical failure rate is 2%, and a small risk of pregnancy remains until you reach menopause.11

Vasectomy is also a surgical procedure. The vas deferens that carry sperm to the penis are blocked. It takes up to three months after the procedure until it is effective in preventing pregnancy. After three months, the man can have his semen analyzed to see whether it contains sperm.11 In the first year, the typical failure rate is 0.15%.6 If the semen is not analyzed, the failure rate in the first year may be as high as 3%.11 Vasectomy is simpler, safer, and less expensive than tubal ligation.2, 11

Emergency contraception:
Even if you take great care to manage your fertility, you may find yourself in a situation where you are at risk of pregnancy. It takes several days after sex before a pregnancy is established.24 Emergency contraception is a safe and effective way of preventing pregnancy for up to five days after unprotected sex. It is not intended to be used as an ongoing contraceptive method. There are two options, including ‘morning after’ pills and the copper-bearing IUD (discussed above). ‘Morning after’ pills work by disrupting ovulation and preventing fertilization. 11, 28 Progestin-only ‘morning after’ pills are generally considered compatible with breastfeeding,26, 27 and breastfeeding can continue uninterrupted.16 Their failure rate is around 10-15% in the first three days after unprotected sex. 28 They become less effective as time passes. Although the ulipristal acetate-containing ‘morning after’ pill has a lower failure rate than the progestin-only ‘morning after’ pill,28 its possible effect on breastfeeding has not been adequately evaluated. Recent research shows that ‘morning after’ pills may also be less effective for obese women.

Unintended pregnancy
If you experience an unintended pregnancy while breastfeeding, you are not alone! About half of all pregnancies in the United States are unintended. As with any pregnancy, you have options, including continuing the pregnancy or having an abortion.

Continuing the pregnancy:
When you breastfeed, the hormone oxytocin is released, and it can cause uterine contractions. These contractions are usually very mild and undetectable. With a healthy pregnancy, continued breastfeeding is considered safe and unlikely to increase the risk for preterm labor.36 Pregnancy, itself, can have a negative effect on milk production. This will have a greater impact on a younger infant who is more dependent on your breastmilk as the primary source of nutrition.

Abortion:
Breastfeeding USA does not take a position on abortion; rather, we are committed to providing evidence-based information.

Three in 10 American women will have an induced abortion in their lifetime. 29 The majority (61%) already have children29 and may still be breastfeeding. In the first trimester, abortion can be done using vacuum aspiration or medicines. If you have decided to terminate a pregnancy and are considering an aspiration abortion, you can discuss pain management options with your health-care provider. Together you can agree on a pain management plan that has no or low adverse effects on breastfeeding.

Medical abortion can be done with a combined regimen of mifepristone and misoprostol.30 Mifepristone passes into breastmilk, and there are no known adverse effects on the breastfed infant.30, 31 One small study found that levels of mifepristone in milk samples taken 6-12 hours after maternal intake ranged from undetectable to low, depending on the dose. The study concluded that with the low dose of mifepristone, “breastfeeding can be safely continued in an uninterrupted manner during medical abortion.”32 Alternatively, you can opt to express and discard milk for two days after taking mifepristone.31 Misoprostol is used for a range of reproductive health indications, including management of postpartum bleeding.33 It passes into breastmilk, and drug levels rise and fall quickly. Misoprostol may temporarily cause infant diarrhea.20, 31 Within five hours, there are no detectable traces left in breastmilk.34

About one in five confirmed pregnancies end in spontaneous abortion (miscarriage). If you experience an incomplete miscarriage (when some pregnancy tissue remains in the uterus) or a missed miscarriage (when fetal death has occurred but the body does not expel the pregnancy), vacuum aspiration or a misoprostol-only regimen may be used as part of your treatment.

Conclusion
Understanding your fertility is an important aspect of life as a new mother. There are many options available for breastfeeding mothers who want or need to manage their fertility. This article is an introduction to this important subject, and we encourage you to continue the conversation with your health-care provider and/or your partner. Remember, you have the right to decide how to manage your fertility. Only you can decide which option is right for you. Being an active, informed health-care consumer can help you achieve your goal.

Online resources
Information about contraceptive methods:
http://bedsider.org/methods
http://www.choiceproject.wustl.edu/en/METHODS
http://www.plannedparenthood.org/health-topics/birth-control-4211.htm
http://www.arhp.org/MethodMatch/
http://www.acog.org/For_Patients
http://ec.princeton.edu/
http://www.cecinfo.org/what-is-ec/iuds-for-ec/

Information about contraception and breastfeeding:
http://kellymom.com/bf/can-i-breastfeed/meds/birthcontrol/
http://kellymom.com/bf/normal/fertility/
http://www.lalecheleague.org/ba/nov01.html
http://www.breastfeedingbasics.com/articles/breastfeeding-and-birth-control
http://www.mother-2-mother.com/menstruation.htm#BirthControl
http://www.who.int/reproductivehealth/publications/family_planning/WHO_RHR_09_13/en/
http://ec.princeton.edu/questions/ecfeeding.html

Citations
[1] Jackson, E. & Glasier, A. (2011). Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstetrics and Gynecology, 117(3), 657-62.
[2] The Academy of Breastfeeding Medicine. (2005). Clinical Protocol Number 13: Contraception during breastfeeding. (Author’s note: This document cannot be retrived online because it is out of date. As of May 12, 2014, the Academy had not released its revised version.)
[3] World Health Organization, Department of Reproductive Health and Research. (2007). Report of a WHO technical consultation on birth spacing. Geneva, Switzerland: World Health Organization.
[4] Zhu, B. P. (2005). The effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynecology and Obstetrics, 89 (Supplement 1), 25–33.
[5] Labbok, M. H. (2007). Breastfeeding, birth spacing, and family planning. Hale & Hartmann’s textbook of human lactation. Eds. Hale, T. W. & Hartmann, P. F. Amarillo, Texas: Hale Publishing
[6] Trussell, J. (2011). Contraceptive Efficacy. Contraceptive Technology, Twentieth Revised Edition. Eds. Hatcher, R. A. et al. New York, NY: Ardent Media.
[7] The Breastfeeding Answer Book. (2012). Retrived on April 23, 2014, from http://www.llli.org/docs/0_babupdate/04babupdatecontraception.pdf
[8] Labbok, M. H. et al. (1997). Multicenter study of the Lactation Amenorrhea Method (LAM): Efficacy, duration and implications for clinical applications. Contraception, 55, 327-36.
[9] Valdéz, V. et al. (2000). The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception, 62, 217-9.
[10] Weschler, T. (2006). Taking Charge of Your Fertility, the Definitive Guide to Natural Birth Control, Pregnancy Achievement and Reproductive Health, Tenth edition. New York, NY: HarperCollins Publishers.
[11] Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs & World Health Organization. (2011). Family planning: a global handbook for providers, 2011 Update. Geneva, Switzerland: World Health Organization.
[12] Jonsson, B., Landgren, B-M. & Eneroth, P. (1991). Effects of various IUDs on the composition of cervical mucus. Contraception, 43, 447-58.
[13] Ortiz, M. E. & Croxatto, H. B. (2007). Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception, 75 (Supplement 6), S16-30.
[14] Health Matters Fact Sheets, Implant. (2010). Retrived on April 23, 2014 from http://www.arhp.org/Publications-and-Resources/Patient-Resources/fact-sh...
[15] American Academy of Pediatrics. (2001). Transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776-789.
[16] Mohrbacher, N. (2010). Breastfeeding Answers Made Simple, a Guide for Helping Mothers. Amarillo, Texas: Hale Publishing.
[17] Interventions Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy: RHL commentary. (2008). Retrived on May 12, 2014 from http://apps.who.int/rhl/fertility/contraception/CD001326_bahamondesl_com...
[18] World Health Organization. (2010). Combined hormonal contraceptive use during the post-partum period. Geneva, Switzerland: World Health Organization.
[19] World Health Organization. (2008). Progestogen-only contraceptive use during lactation and its effects on the neonate. Geneva, Switzerland: World Health Organization.
[20] Hale, T. W. (2008). Medications and Mothers’ Milk, Thirteenth edition. Amarillo, Texas: Pharmasoft Medical Publishing.
[21] International Consortium for Emergency Contraception. (2012). The Intrauterine Device (IUD) for Emergency Contraception. New York, NY: Family Care International.
[22] Schwarz, E. B. & Trussell, J. (2011). Emergency Contraception. Contraceptive Technology, Twentieth Revised Edition. Eds. Hatcher, R. A. et al. New York, NY: Ardent Media.
[23] The American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. (2012). Committee Opinion Number 530: Access to Postpartum Sterilization. Obstetrics and Gynecology, 120, 212-215.
[24] International Planned Parenthood Federation. (2004). Medical and Service Delivery Guidelines for Sexual and Reproductive Health Services, Third Edition. London, United Kingdom, International Planned Parenthood Federation.
[25] The difference between medical abortion and emergency contraceptive pills. (2010). Retrived on April 23, 2014 from http://www.arhp.org/publications-andresources/clinical-fact-sheets/mifep...
[26] Gainer, E. et al. (2007). Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Human Reproduction, 22(6), 1578–1584.
[27] Polakow-Farkash, S. et al. (2013). Levonorgestrel used for emergency contraception during lactation, a prospective observational cohort study on maternal and infant safety. Journal of Maternal, Fetal and Neonatal Medicine, 26(3), 219-221.
[28] International Consortium for Emergency Contraception. (2013). Clinical Summary: Emergency contraceptive pills. New York, NY: Family Care International.
[29] Guttmacher Institute. (2014). Induced Abortion in the United States. New York, NY: Guttmacher Institute.
[30] Ipas. (2009). Medical Abortion Study Guide. Chapel Hill, North Carolina: Ipas.
[31] My bpas Guide. (2012). Retrived on April 23, 2014 from http://www.bpas.org/js/filemanager/files/my_bpas_guide_jul_12.pdf
[32] Saav, I. et al. 2010. Medical abortion in lactating women: low levels of mifepristone in breast milk. Acta Obstetricia et Gynecologica Scandinavica, 89(5), 618-622.
[33] Allen, R. & O’Brien, B. M. (2009). Uses of Misoprostol in Obstetrics and Gynecology. Reviews in Obstetrics and Gynecology, 2(3), 159-168.
[34] Vogel, D. et al. (2004). Misoprostol versus methylergometrine: Pharmacokinetics in human milk. American Journal of Obstetrics and Gynecology, 191(6), 2168-73.
[35] Abdel-Aleem, H., et al. (2003). The pharmacokinetics of the prostaglandin E1 analogue misoprostol in plasma and colostrum after postpartum oral administration. European Journal of Obstetrics and Gynecology and Reproductive Biology, 108, 25-8.
[36] Ayrim, A., Gunduz S., Akcal B., Kafali, H. (2014). Breastfeeding Throughout Pregnancy in Turkish Women. Breastfeed Med, 9(3), 157-160.

Copyright Breastfeeding USA. All rights reserved. August 2014

Blebs: Teeny Tiny Meanies

How can something that is so small hurt so much? That is the question I asked myself when I developed a bleb on my right nipple. Then asked again when the next one developed in the exact same spot. And again. And again. I asked myself this question eight times for a total of eight recurrent blebs. Ouch!

Blebs made it hurt to breastfeed and also to not breastfeed. Any pressure, even the slightest, on my nipple made me cringe. That included wearing a bra or top. I remember lying in bed with an open nipple pore (after I had wiped away a bleb) trying to sleep and feeling excruciating pain. I remember being confused by that because I had expected the pain to go away once the bleb had been removed. A lactation consultant told me the pain was nerves responding to air entering the nipple pore. True? I don’t know. I just know that until I developed my first bleb, I had never experienced pain like this before.

So what is a bleb? A bleb (also called a milk blister or blocked nipple pore) is what forms when a little bit of skin grows over a nipple pore (milk duct opening), and breast milk backs up behind it. According to kellymom.com, “A milk blister usually shows up as a painful white, clear or yellow dot on the nipple or areola, and the pain tends to be focused at that spot and just behind it. If you compress the breast so that milk is forced down the ducts, the blister will typically bulge outward. Milk blisters can be persistent and very painful during feeding, and may remain for several days or weeks and then spontaneously heal when the skin peels away from the affected area.” 1

Why do some breastfeeding women develop milk blebs? There are a variety of possibilities, such as oversupply, wearing a tight bra or something that puts pressure on that area of the breast, and latch or suck problems.

I dealt with oversupply for the first several months after my second baby was born. She had a posterior tongue tie and upper lip tie, which created latch problems. These eight blebs occurred during her first twelve weeks while I was on maternity leave. I remember vividly the relief I felt each time they disappeared, followed by dread each time they reoccurred.

How can we get rid of blebs and better yet, how can we prevent them? Before breastfeeding, soak the breast in warm water or apply a warm, wet compress. This may make it easier for the baby to remove the bleb while nursing. If that works, go ahead and treat the area to assist in healing (e.g. saline rinse, application of expressed breastmilk, application of an antibiotic ointment that is compatible with breastfeeding). If the bleb remains in place after breastfeeding, however, there are other steps that can be taken to eliminate it. Some sources suggest applying olive oil to a cotton ball and wearing it in the bra so that the oil softens the skin where the bleb is located 2. Afterward, try to remove the bleb by rubbing it gently with a warm, wet washcloth. If the bleb still remains, see a health-care provider, who can open the bleb with a sterile needle so that the milk can flow out.

If blebs recur, consider eliminating saturated fat from your diet and taking lecithin in either liquid (one tablespoon three times per day) or capsule (one or two 1,200 mg three or four times per day) 2,3 . Be aware that lecithin is often a soy-based product; check the label for the source. Identifying and resolving the underlying cause for recurrent blebs goes a long way toward preventing more of them.

My own story went like this: As I wrote at the beginning of this article, I had eight blebs back to back to back to….you get the idea. I soaked my breast in warm water before every feeding. I often started each feeding with the unaffected breast because my daughter’s hunger would be somewhat satisfied when she got to my right breast. Consequently, her sucking wasn't as vigorous. After each feeding, I sprayed my breasts with a homemade saline solution. Breastfeeding, however, was not enough to open up the blebs. The only way I could remove them was to rub them with a washcloth in the shower. During, in between, and even for months after the blebs went away (for fear they would return), every evening after my daughter was asleep I put an olive oil-soaked cotton ball in my (underwire-free) nursing bra. I kept it in my bra for at least 15 minutes and then hand expressed so that more milk didn't back up behind the nipple pore. Thankfully after the blebs stopped forming, the nipple pore remained open. Even today, almost three years later, that one spot still has a wide, visible opening.

I hope you never get a bleb. If you do, I hope the information presented here helps you find resolution quickly.

References:

  1. http://kellymom.com/bf/concerns/mother/nipplebleb/
  2. Mohrbacher, N. (2010). Breastfeeding Answers Made Simple. Hale Publishing, L.P. 658-659.
  3. Mohrbacher, N. (2013). Breastfeeding Solutions: Quick Tips for the Most Common Nursing Challenges. New Harbinger Publications, 90-91.

Published June 2014

Copyright Breastfeeding USA 2014. All rights reserved.

Breastfeeding a Baby with a Cleft Lip and or Palate - The Red Carpet Treatment

After having overcome some breastfeeding challenges with my first daughter, I was looking forward to an easier experience the second time around. Finding out that my second daughter, Miriam, would be born with a unilateral cleft lip and palate was a cold shower - the first of many. I didn't know exactly how it would affect breastfeeding, but I knew deep down that my dreams of a carefree breastfeeding experience were no longer going to come true. When I got home, I took my breastfeeding reference book off the shelf and discovered that breastfeeding (as I then imagined it - exclusive breastfeeding at the breast), with a cleft lip and palate, may not have even been possible. I was thoroughly devastated.

I managed to muddle through my daughter’s first seven months, patching together information from different sources, feeding her expressed breast milk and partially breastfeeding at the breast as she got older, until her palate operation (at 6 ½ months) after which she learnt to breastfeed unaided. In the seven years since, I have spoken with a multitude of parents whose babies have clefts, who have recounted their difficulties with breastfeeding. From their experiences and my own research, I have come to the conclusion that many difficulties faced by the parent and baby are management issues -- lack of support, lack of information, and lack of practical help. Instead of receiving the best breastfeeding support available (i.e. the red carpet treatment), these mother-baby dyads and their families are often forgotten, or their difficulties are underestimated.

In the US, a cleft lip and/or palate affect approximately 1 in 600 live births 1. Frequency of the conditions varies from country to country. Despite the incidence of clefts, there is very little in the breastfeeding literature about breastfeeding with a cleft lip and palate, and very few breastfeeding counselors and lactation consultants seem to have direct and repeated experience with it. Even my family doctor knew very little about the condition; we had to do quite a bit of research before finding my daughter’s future cleft repair team. Now, with the number of Internet parent support groups 1, 2, finding information is a little more straightforward. There is still a long way to go in many countries, however, before a positive diagnosis of cleft lip and/or palate is followed by relevant and reliable information on what to do next.

Cleft lip and/or palate are umbrella terms for various presentations of a facial cleft 3. A cleft lip can affect the lip only, lip and gum (alveolar ridge), and may possibly include a submucosal cleft palate. A solitary cleft palate can be submucosal (not seen by the eye and frequently missed during postnatal checks), or involve the soft palate, or both hard and soft palates. A cleft lip and palate will include lip, gum (alveolar ridge), and hard and soft palates. The size of the cleft can vary from a few millimeters to a centimeter or more.

Different clefts will impact breastfeeding in different ways 4, 5. The recently revised Academy of Breastfeeding Medicine guidelines for breastfeeding with a cleft lip and/or palates, note that the “literature describing breastfeeding outcomes is limited, and the evidence is anecdotal and contradictory.” The guidelines state that both suction and compression (pressing breast between tongue and jaw) are necessary for milk transfer during breastfeeding and that the amount of oral pressure generated during feeding will depend on the size and type of cleft and the maturity of the baby. For this reason, babies with a cleft lip only are more likely to breastfeed than those with a cleft palate or a cleft lip and palate. Some babies with small clefts of the soft palate generate suction, but others with larger clefts of the soft and/or hard palate may not. Older babies generate more suction than newborns and premature babies.

Anecdotally, many mothers recount that they have been successful at breastfeeding exclusively when their baby presents with a cleft lip only (even when bilateral, and even including the alveolar ridge or gum). There is some discussion over whether a baby with a cleft of the soft palate can manage to breastfeed exclusively. I have come across four different personal accounts of mothers who have successfully breastfed (at the breast) a baby with a cleft of the soft palate 6, 7, 8, 9. Breastfeeding an infant with both a cleft lip and palate appears to be more elusive, although one medical study in Thailand9 recounts success with exclusive breastfeeding. Hopefully, more studies will be forthcoming.

From my experience, I believe that with optimal breastfeeding support immediately after birth and in the following days, babies with clefts will be able to show their true breastfeeding potential. I call this “the red carpet treatment.” Expert support in the very early days after birth should help parents to avoid most of the more common breastfeeding difficulties, especially problems associated with low milk production. What we parents often don’t receive is help getting our babies to latch on in the first hours after birth, evaluation of breastfeeding and milk transfer, and determining whether supplementing is necessary and how that should be done. This “red carpet treatment” would help ensure that we maximize our milk production, whether the baby is receiving milk at the breast or via other means. When milk production is insufficient, we also need to know what our options are when exclusive breastfeeding is not possible.

The “red carpet treatment” of breastfeeding support for a cleft-affected infant might include:

  • Early skin-to-skin contact and help with latching within the first hour after birth 10
  • Early evaluation of breastfeeding, positioning, and milk transfer
  • When milk transfer at the breast is insufficient, or baby is unable to latch, help with colostrum expression, within first hour after birth and at least every three hours after that 11
  • Assistance with and instruction of optimal expression techniques (hand expression, or combination of hand expression/double electric pumping, in first 48 hours or until copious milk production begins, double electric pumping combined with ‘hands-on’ techniques subsequently) 12
  • When milk production is insufficient, help with implementing strategies for maximizing milk transfer 13 and supply, such as hot compresses before a feed/pumping session; breast massages before or during feed/pumping session; breast compressions; breast massage and reverse pressure softening 14 to encourage milk let down; expressing after breastfeeds to build supply; and the use of galactogogues 13
  • Evaluation of whether and how to supplement – via bottle, syringe, spoon, or an at-the-breast supplementer; and full information about options including donor milk and formula
  • Psychological support
  • Practical support – a feeding/pumping plan and how to find the time to manage that along with family/home responsibilities and time for looking after one's self

Some parents are concerned about knowing the exact presentation of their child's cleft prior to birth. Knowledge of the cleft can facilitate preparation for breastfeeding and researching and choosing a cleft surgeon or team, but is not necessary. Currently, in the United Kingdom, it is encouraged to express colostrum prenatally 15. when expecting a baby affected by cleft lip or palate, in case a supplement is required after birth. This colostrum is a great backup, although it is important that using this backup not take the place of early breastfeeding initiation and/or frequent postnatal expression, vital for establishing good milk production.

Mothers, who have been successful with at-the-breast feeding, recount techniques that they have found useful, including:

  • Closing lip with fingers to help make a seal
  • Experimenting with different positions to enable baby to maintain suck and swallow, such as using the breast tissue to close the cleft
  • Dealing with early signs of engorgement due to inefficient or incomplete drainage of all areas of the breast such as rotating the position of the baby's mouth/latch around the breast, reverse pressure softening, hand expression and pumping
  • Maintaining an abundant milk supply
  • Assisting milk letdown via hand expression, breast compressions, and visualization of the milk flowing

Surgical options
Timing of cleft surgery and surgical protocols vary enormously from country to country and from surgeon to surgeon. There are various programs in force attempting to standardize cleft protocols 16, 17. The cleft may be repaired in one surgery or multiple stages - the palate and lip together or separately. The lip may be repaired as early as two months or as late as a year and a half. The palate may be repaired in the early weeks, at around six months, or after the first birthday. Some surgical teams will allow breastfeeding/bottle feeding immediately after surgery, while others will require temporary weaning from breast/bottle for some weeks. Breastfeeding is usually possible because the breast is soft and pliable, conforming to the baby's mouth.

Exclusively breastfed babies will often find comfort in breastfeeding immediately after surgery, although some babies may refuse the breast for hours or days. Babies who have undergone palate surgery are often reluctant to feed at all in the early days after repair, and this can be challenging. A baby may be more willing to feed with a cup or spoon because lip suction is not needed. It is important to maintain milk production during this transitional period.

Transitioning to the Breast
After palate repair, there is a chance that the baby will transition to the breast almost fully (palate repair generally occurs from five/six months onwards and solids may also be introduced). This can be a delicate time as many factors occur simultaneously. The baby may be reluctant to feed at all either at the breast, via bottle, or spoon-fed solids as the palate surgery involves the incisioning and redirection of the palatal muscles. A decrease in milk production may occur due to fatigue and stress post-surgery. Transitioning to the breast 20 requires extra time and effort.

Transitioning to the breast after palate surgery is the last great challenge in breastfeeding a cleft-affected child - 'the last hump' in the difficult breastfeeding journey. When my own daughter was recovering from palate surgery (age six months), she went on an all out 'nursing strike' and would scream every time I attempted to latch her onto the breast. I decided to put in one last major effort, dedicating myself entirely to pumping AND nursing. It was a very intense time. In the end, thanks to a silicone nipple shield taped over a supplementing device, Miriam accepted the breast again. Within a couple of days, she was breastfeeding solo without bottles and pumped milk. It was a huge relief, and each time we sat down to nurse after that was a celebration. Many other mothers recount similar experiences.

However, not every baby does go on to breastfeed unaided at the breast. One mother recounts that her son breastfed unaided for around a month before a fistule opened in his palate; he lost suction and ceased breastfeeding. Others have found the process of transitioning to the breast too stressful for both mother and baby. Some babies are more intent on learning to breastfeed, while others are not. Transitioning to the breast should not be our only goal.

Evaluating Priorities

One mother of triplets (all three with a cleft!) recounts that she 'raised the white flag' when her sons reached six months. It is important to keep that white flag handy. Sometimes it is breastfeeding and/or pumping that will be let go, or it could be something else in our everyday routine and family organization. Evaluating priorities is an ongoing process, and it can be useful to discuss this with a Breastfeeding USA Counselor or a Lactation Consultant (IBCLC).

We all need to feel that we are doing the best for our children. When breastfeeding is harder than we expect, it helps to be reminded that we are doing our best, even if our best is less than we would like. Breastfeeding does not have to be limited to exclusive breastfeeding. The World Health Organization defines breastfeeding 18 as an infant being fed human milk, whether from the breast or expressed (including donor milk), and other foods - we shouldn't lose sight of that. Every drop of breast milk that we provide is a cause for celebration.

Over the years that have followed my own breastfeeding experience, I have sought out other breastfeeding families, both to offer support, but also to learn more about what exactly makes breastfeeding a baby with a cleft lip and/or palate difficult. The more I hear, the more I realize that we don’t have enough expert support. Parents often arrive at birth very well informed, but lack hands-on help and an expert eye. Sometimes parents encounter criticism and discouragement. I encourage other parents to tell their stories – whether they have attempted breastfeeding and if so, whether they have breastfed partially or fully. Doing so helps to increase the body of knowledge on breastfeeding with a cleft lip and/or palate. I continue to seek out resources, both print and video, and have created a website 19 so that parents and health-care workers have a starting point for their own research.

It takes more than the efforts of one parent to breastfeed a cleft-affected child. It takes not only the patience and support of the whole family, but also the community, especially the health-care community that surrounds us. What we need is more than just encouragement and information; we also need the right support - "the red carpet treatment."

PARENT RESOURCES

REFERENCES

  1. Farrow, A, 2013, One cleft is not like another, (accessed October 2013) http://cleftlipandpalatebreastfeeding.com/2013/08/one-cleft-is-not-like-...
  2. Reilly, S., et al., revised 2013, ABM Clinical protocol #17: guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate, revised 2013, Academy of Breastfeeding Medicine
  3. Farrow, A., What to expect, http://cleftlipandpalatebreastfeeding.com/2013/07/what-to-expect/ (accessed October 2013)
  4. Grady,E,. 1983, Nursing my baby with a cleft of the soft palate, Schaumburg, Illinois, La Leche League International, 1983 (out of print)
  5. Cleft palate breastfeeding (video) http://www.youtube.com/watch?v=BpqqYQlKDeA (accessed October 2013)
  6. Cwir, J. (ed), 2013, I wish I’d known….how much I’d love you!’, CreateSpace Independent Publishing Platform
  7. Pathumwiwatana P, et al. The promotion of exclusive breastfeeding in infants with complete cleft lip and palate during the first 6 months after childbirth at Srinagarind Hospital, Khon Kaen Province, Thailand. J Med Assoc Thai 2010; 93. Suppl 4; S71-77
  8. WHO Breastfeeding – early initiation e-Library of Evidence for Nutrition Actions (eLENA) http://www.who.int/elena/titles/early_breastfeeding/en/index.html (accessed October 2013)
  9. West, D., Maximizing a Mother’s Milk Production Capability, http://www.breastfeedingconferences.com.au/search_results.php?cx=0074617... (accessed October 2013)
  10. West, D. and Marasco, L., (2009). The Breastfeeding Mother's Guide to Making More Milk. New York, NY: McGraw Hill.
  11. www.lowmilksupply.org
  12. Cotterman, J., Reverse Pressure Softening http://www.breastfeedingmadesimple.com/SimplerRPSsheet2.doc (accessed October 2013)
  13. Soper, D., Expressing Milk Before Birth: A Tool for Use in Special Circumstances
    https://breastfeedingusa.org/content/article/expressing-milk-birth-tool-... (accessed October 2013)V
  14. The Americleft Outcomes Project http://www.acpa-cpf.org/research/the_americleft_outcomes_project/
  15. Eurocleft Journal of Cranio-Maxillofacial Surgery (2001) 29,(3):131-40; discussion 141-2
    # 2001 European Association for Cranio-Maxillofacial Surgery
    doi:10.1054/jcms.2001.0217, available online at http://www.idealibrary.com on (accessed October 2013)
  16. The World Health Organization's infant feeding recommendation http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/
  17. www.cleftlipandpalatebreastfeeding.com
  18. Australian Breastfeeding Association: Breastfeeding babies with clefts of lip and/or palate https://www.breastfeeding.asn.au/bfinfo/cleftpalate.html

Copyright Breastfeeding USA 2014. All Rights Reserved

Syndicate content