Breastfeeding Information

Breastfeeding Information 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

A Case for Using Galactagogues as a Last Resort for Increasing 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

Amazing Mammal Mothers Making Milk

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.

Amazing Mammal Mothers Making Milk

You may have heard someone say that breastfeeding our babies is a basic human right. However, it isn't uniquely human. In fact, we share breastfeeding with non-human mammals—cats, cows, and capybara, to name a few. In fact, the term mammal comes from the word mammalis, which is of Latin origin and means "from the breast." Mammals share many features, such as warm-bloodedness, hair, a four-chambered heart, as well as feeding of the infant with milk from the mammary glands.

Does breastfeeding in humans have any similarity to breastfeeding in other mammals? As a zoologist and former zookeeper, I've often been struck by the similarities of mothering among mammals, a very diverse group in many other respects. I've seen giraffe, camels, antelope, gazelles, kangaroos, babirusa, zebras, elephants, and lemurs nurse their own and, sometimes, their close relatives' infants. The basic act of nursing is very similar to our own, mechanically speaking. Of course, the biggest similarity is that we all, humans and non-humans, are evolutionarily and biologically built for the job! What else do we share with these non-human mothers? Consider some aspects of breastfeeding in the human condition and how these compare with other mammals' parenting practices.

I'm Thirsty
For me, there is nothing as strong as that sudden desire for water that I feel when I first sit down and feed my baby. While nursing, I feel like I need to consume about twice as much water as I would when I am not breastfeeding, especially when out in the heat or being physically active. As a zookeeper working out in the hot sun, sometimes it felt like I couldn't possibly take in enough water to quench my thirst between pumping sessions, and I'd joke with the zoo's veterinarians about hooking me up to IV fluids. Of course, being a little thirstier than usual isn't only a human thing. Being thirsty can even change an animal's natural behaviors, as seen in the Grevy's zebra and Somali wild ass.

The Somali wild ass and the Grevy's zebra are both tough animals from the Horn of Africa, found in Kenya, Somalia, Eritrea, and Ethiopia. They are Equids, which means they are related to horses, but they've both become specialists in their desert lifestyle. They can eat very unpalatable and dry vegetation—coarse brush, sedges, and thorny plants that domestic goats, cows, and even camels avoid. Adults of both species have adapted to have very low water requirements and can go up to five days without drinking. Naturally, lactating females are different. Lactating Somali wild ass females need to drink every day, while Grevy's zebra females need to drink at least every other day. During lactation, females of both species have a smaller range which allows them to stay closer to water sources. For Equids and for us, the behavior is similar: keep a water source nearby and drink to thirst.

What a Big Baby!
The blue whale is the largest animal alive—adults can be 75-100 feet long and weigh more than 150 tons, the weight of almost 4 semi-trucks with full loads. Baby blue whales have to coordinate breastfeeding with surfacing to breathe and are one of the few species that have to learn to do something before they can breastfeed. A mother blue whale will guide her newly-born offspring up to the surface to catch its first breath before going underwater again to nurse. Babies will consume up to 50 gallons of milk a day, which is of toothpaste consistency and 35-50% fat. All of this fat is needed, of course, because a baby gains around 10 lbs an hour and about 250 lbs—about as much as LeBron James, professional basketball player—in a day.

Some mothers can really relate to a quickly gaining baby. My own son, for instance, never lost weight in the hospital, was always in the 99% for weight, and as a preschooler currently dwarfs many second graders. It's important to realize that all babies grow at different rates and that quickly growing breastfed babies aren't overweight; they are just following their own growth pattern, which is frequently genetic. This can be reassuring to know when your in-laws start making comments about your own big (or petite, for that matter) baby.

Leaky Milk
How does a mammal so primitive that it lacks nipples still feed its baby? The platypus, an egg-laying mammal from Australia, has so many quirky characteristics that the first specimen brought to Europe was considered a hoax. This funny looking mammal not only has flipper feet, a beaver-like tail, and a duck-shaped bill, but it is also one of the few mammals that is venomous. The way in which she feeds her infant is also a unique characteristic. Since the platypus does not have nipples, she secretes milk from her mammary glands onto her skin and her offspring lap up the milk on her chest as she reclines in her den.

Some mothers leak a little milk now and then. Other mothers never leak any milk. Then there are the mothers who wake up to a soaking wet sheet in the morning, due to milk leakage overnight. These moms also carry plenty of breast pads and an extra shirt in their diaper bag, just in case. Leaking milk isn't fun, but when it happens to us, we can remember the platypus and her soggy feeding condition.

Your Older Nursling
Let's face it—some folks in our society today frown on nursing a baby older than 12 months, the minimum duration recommended by the American Academy of Pediatrics. Many women with older nurslings breastfeed "in the closet"—secretly at home without their friends', pediatrician's, or in-laws' knowledge. Some feel embarrassed or ashamed to still be nursing. Even those who don't feel embarrassed may just shy away from revealing the fact that their toddler (or preschooler) is nursing in order to avoid receiving well meaning advice or being in conflict with others who have chosen a different parenting path. A common but mistaken idea in our society is that breastfeeding should be over by the baby's first birthday. As a friend of mine once said to her pediatrician, "Why is breastfeeding so great for the first 365 days, but on day 366, it suddenly isn't okay anymore?"

Let’s consider the nursing habits of some of our closest primate relatives. The chimpanzee, gorilla, and orangutan all share more than 95% of our DNA. Their parenting styles are very similar to ours—they carry their infants continually and nurse on demand. The weaning age of a chimpanzee is around 48 months, a gorilla will nurse until 52 months, and a Borneo orangutan will nurse on average 42 months, and may continue to nurse for as long as 5-7 years! These apes all have a longer average breastfeeding period than industrialized human societies today, despite the fact that human infants are born less developed than any of the apes, are less self-sufficient for longer, and have a longer infancy. The typical nursing period in pastoral societies in developing countries is much nearer the durations seen in the apes. It's time that we forget about the 12-month weaning recommendation and go with the flow.

Gotta Go?
The okapi is a secretive creature related to a giraffe, which is found in the rainforests of the Democratic Republic of the Congo. It has a neck somewhat shorter than a giraffe and is dark brown, except for having white stripes on its rear end. As a zookeeper, I've had the pleasure of watching several okapi being born. Before our first okapi was born, we prepared for the birth of these unique animals by doing some research. We discovered that the newborn okapi does not defecate for up to a month after birth because it uses its mother's milk so efficiently. This may have been an evolutionary advantage because okapi babies do not follow their mothers, but remain in hiding, where defecation might alert a predator to their presence. Some of the first okapi babies born in zoos were treated by vet staff for constipation when, in fact, this stooling pattern was a normal phenomenon.

Of course, breastfed human babies do not follow the okapi pattern of defecation. However, sometimes breastfed babies over a month do not defecate as frequently as a health care professional would expect. A mother may be fearful that her baby is constipated. An older baby may defecate once daily. Some babies have been reported to defecate every few days or even once every five days or longer. Whether there is a reason for this defecation pattern compared to more frequently stooling breastfed babies isn't entirely clear. Generally, as long as the baby is gaining well, feeding normally, and is otherwise healthy, it's considered a normal variation to have a longer stretch between bowel movements. Also, it's important to realize that consistency of stool, rather than frequency, determines constipation, which is rare in breastfed babies. When a baby is constipated, his stool is hard in consistency, a far cry from the soft, mustardy-seeded stools typical of the breastfed baby.

He's Constantly Nursing!
My second born, the big boy, was also one of those babies who wanted to nurse very frequently. Especially at the beginning, it seemed like I'd scarcely settle him down and he'd want to be up and attached again. He'd sleep in a wrap in my arms, always just a wiggle away from another snack. I've commiserated with other moms about similar nurslings—those who just want to be attached to mom nearly 24/7.

When we have a baby with this nursing pattern, it may remind us of the kangaroo. A kangaroo joey is very immature at birth, compared to other mammals. At the size of a lima bean and the look of a fetus, it crawls up its mother's body and attaches to her nipple. And there it remains, continuously attached inside her pouch. Her nipple swells in the baby's mouth so that the baby will stay permanently attached during the first stages of lactation. In fact, the kangaroo newborn doesn't even have the ability to detach and reattach herself; if she unlatches before she's developmentally ready, she could die. As she develops, she will gain fur and her eyes will develop. Eventually, the baby will cease her continuous nursing and begin to stick her head out of the pouch. Later, she will climb out of the pouch to explore but will go back in when she needs comfort, a safe place to go, or a meal. Finally, she may be too large to return to the pouch but may continue to nurse by putting her head back inside the pouch. Our continuously nursing newborns? They'll grow out of it, too.

Health Consequences of Bottlefeeding
There are many reasons why women may resort to formula feeding, even when they are aware of the health risks associated with it. Frequently, this is a very complicated and challenging decision-making process. Wild mammals do not have infant feeding choices to make. If the mother is unable to produce enough milk, becomes separated from her young, or is eaten by a predator, infants not at or near weaning age will typically die. Some primates and a few other mammals, such as elephants, will occasionally feed orphaned infants, especially ones they are related to, with their own milk. There are even a few cases of cross-species milk sharing (if you're interested, do a Google search on interspecies nursing), but they are striking because they are not the norm. Also, since milk is species-specific, cross-fostered babies do not always survive or have the best of health.

Non-human, bottle-fed mammals do exist on farms, in sanctuaries or zoos. I've been lucky to watch many young mammals feeding from their mothers (or sometimes aunties, if mother doesn't happen to be nearby). There are rare cases when a newborn has to be hand-reared with a bottle--if the mother dies or becomes too ill to care for her youngster. Hand-reared young mammals can be less robust when compared to their mother-reared counterparts. They may be smaller and have more health problems, such as diarrhea. While adequate milk replacers have allowed us to save the lives of these young animals, rarely do they enjoy great health. Also, the bonding and natural behaviors they learn while nursing from their mothers seem to help them prepare for parenthood, themselves. This may be why hand-reared female mammals do not always have the skills to raise their own babies. Hand rearing in zoos and sanctuaries is now done sparingly, with a trend towards keeping the offspring with other members of the same species which may, in turn, allow the hand-reared baby a better chance of parenting her own offspring. I can't help drawing a parallel to our own society. When our young people grow up around nursing babies, when society sees nursing as a norm, and when our own mothers have nursed us, breastfeeding may come more easily for us, as well.

References

10 Incredible Tales of Interspecies Nursing. Retrieved 4/12/2015 from http://scribol.com/environment/10-incredible-tales-of-interspecies-nursi...

About Grevy's Zebras. Retrieved 4/12/15 from http://www.grevyszebratrust.org/about-grevy-zebra.html

Blue Whale. (2015). Retrieved 4/12/15 from http://www.marinemammalcenter.org/education/marine-mammal-information/ce...

Bonyata, K. (2011). Is My Breastfed Baby Gaining Too Much Weight? Retrieved 4/12/2015 from http://kellymom.com/bf/normal/weight-toomuch/

Estes, R.D. (2012). The Behavior Guide to African Mammals. Los Angeles, CA: University of California Press, 235-249.

Feldhamer, G. et al. (1999). Mammalogy: Adaptation, Diversity and Ecology. Boston, Ma: McGraw Hill, 5, 177-179, 364-365.

Lindsey, S.L. (1996). The Okapi: Mysterious Animal of Congo-Zaire. Austin, TX: University of Texas Press, 87-110

Lauwers, J and Swisher, A. (2011). Counseling the Nursing Mother: A Lactation Consultant's Guide. Sudbury, MA: Jones and Bartlett Learning, 306, 416, 429-432

Moyal, A. (2004). Platypus: The Extraordinary Story of How a Curious Creature Baffled the World. Baltimore, MD: John Hopkins University Press, 120-135.

Poelker, C. (2011). Rearing Antelope: Three Thriving Examples at the Saint Louis Zoo. Animal Keeper's Forum. 38(7/8). 340-343.

Rowe, N. (1996). The Pictorial Guide to the Living Primates. Charlestown, RI: Pogonias Press, 219-234.

© Copyright Breastfeeding USA, Inc. 2015. All rights reserved.

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.

A Case for Using Galactagogues as a Last Resort for Increasing Milk Production

One of the most common questions I receive by email or Facebook message from mothers seeking breastfeeding support is, “What can I take, eat, or drink to increase my supply?” The Internet contains countless articles, blogs, advertisements, and testimonials about using galactagogues to increase milk production in breastfeeding mothers. A galactagogue is a food, drink, medication, or supplement that is ingested by the mother with the intention of increasing the amount of milk produced. The concern I find with answering this type of inquiry is that most of the time, mothers are looking for a quick and easy way to boost supply, when there may either be an underlying problem related to milk production that needs to be addressed, or the mother may already have an adequate milk supply.

In addition, while there is certainly a great deal of anecdotal evidence of the use of some foods or supplements successfully increasing milk supply, little research exists supporting the effectiveness of galactagogues to increase milk production. This makes it difficult to be confident that their use is safe or effective. The Academy of Breastfeeding Medicine has noted the need for research in the area of galactagogues stating, “There is a clear need for well-designed, adequately powered, randomized controlled trials using adequate doses of galactagogues in populations of women in which both the experimental and control groups receive modern, appropriate lactation support.” This lack of research leaves mothers who seek to increase milk production through galactagogues vulnerable to potential unknown interactions with other medications they may be taking, other unknown safety risks, or simply wasting money on useless supplements in the hopes of correcting a problem that can often be addressed without consideration of galactagogues.

If you are in a situation where you are seeking to increase your milk production, the first and most important thing to determine is whether you are truly not producing enough. Many mothers expect that their supply will be abundant and feel that they are not making enough milk, when they actually have a perfectly sufficient supply. Some mothers will find that while their babies seem to be satisfied after feeding, they are unable to ever express very much when pumping. It is important to note that the amount of milk you are able to pump does not necessarily correlate to the amount that you are producing. No pump can remove milk as efficiently as your baby can, and you may be transferring significantly more while feeding at the breast than you are while pumping.

To determine whether you are making enough milk, examine your baby’s weight gain and diaper output. By the fourth day of life, your baby should be having at least four to six wet diapers per day, and this should continue as your baby grows. In the first few weeks, babies should have at least two to three yellow, seedy stools per day. However, after the first month or two, the frequency of bowel movements will start to vary more by each individual baby, with some having multiple bowel movements each day and some having only one every few days. Your baby’s health care provider can confirm for you whether your baby’s weight gain is sufficient at your well baby visits. If you have concerns, however, you may consider seeking assistance from an IBCLC, or International Board Certified Lactation Consultant, who can help you assess whether your baby is getting enough milk. You can find the nearest IBCLC at www.ilca.org. You can find more information on whether your baby is getting enough milk on the Breastfeeding USA website or the Ask Dr. Sears website.

If your baby is not gaining enough weight and/or is not producing enough urine or stool, don’t simply jump to the conclusion that you are not producing enough milk. There can be a number of explanations for why a baby may not be gaining weight as quickly as expected, many of which are easily addressed. If you are unable to determine the problem, this is a good time to contact a Breastfeeding USA Counselor or an IBCLC. Please see the end of this article for information on finding someone who can help.

Before turning to galactagogues, the tactics below may be useful in helping improve a reduced supply or a perceived reduced supply due to other breastfeeding issues.

  • Ensure that you are following your baby’s feeding cues. Babies can’t speak, but they are excellent communicators. Once you learn to “speak” their language, your baby will let you know when he wants to breastfeed, as well as when he is finished. Feeding on demand – or when your baby cues you that he wants to feed – is one of the most important things you can do to ensure you are feeding him frequently enough. Breastfeeding works on supply and demand, which means that when you feed your baby, your breasts receive the “message” that they need to make more milk. If you feed baby when he is hungry and until he indicates that he is full, your breasts will “know” how much milk to make. Conversely, if you schedule feedings or limit the amount of time your baby spends eating from each breast, your baby may not get the amount of milk he needs, and your body will not receive the signal that more milk needs to be produced.

    Crying is a late sign of hunger in infants. Babies will give cues such as bringing their hands to their mouths and opening and closing their mouths as they begin to become hungry. They will generally then move into fidgeting or trying to position their bodies to access the breast and rooting (moving his head toward you when touched). Responding to these early cues will help to ensure that baby is fed when hungry. In addition, babies will usually continue to nurse on one breast until they are finished with that side. They will either unlatch or change from swallowing milk to non-nutritive sucking. At this time, you can offer the other breast, and baby will feed until he is full. There are exceptions, particularly in the early days when babies may fall asleep at the breast, even when not quite finished eating. Usually, baby will cue you both when he is hungry and when he is full.

  • Feed your baby frequently. Nothing is better at signaling your body to make more milk than feeding your baby. Every time your baby breastfeeds, your body learns. Both removal of milk from the breast and stimulation of the nipple by suckling tell your body that more milk will be needed to continue feeding your baby. If you feel that you may not be producing enough milk, try putting baby to the breast more often. Feedings need not be limited to after waking or before sleeping, or any other time when your baby shows obvious hunger. Offering the breast often will allow your baby to feed as often as she needs, and the more frequently she breastfeeds, the greater your supply will be.
  • Make sure that you have a good, deep latch. Latch. is a topic that could be (and has been) discussed in its own article. For a variety of reasons, it is crucial that the baby has a deep latch with a good amount of breast tissue behind the nipple in his mouth. First, a poor latch can lead to pain for mom. A small amount of discomfort in the early days for the first few seconds of breastfeeding is normal, but pain that lasts after the first few days or lasts throughout the feeding or between feedings is not. Toe-curling pain is never normal and should be addressed immediately. A suboptimal latch can also lead to poor milk transfer and cause reduced milk supply.

    If you are concerned that you may not be getting a good deep latch, a breastfeeding professional or volunteer Breastfeeding USA Counselor can be helpful in assisting you to improve it.

  • If you are pumping, make sure that you are pumping often and long enough. If you are pumping while away from your baby, make sure that you are doing so at least once for every missed feeding whenever possible. Pumping less frequently can lead to lowered milk production. In addition, make sure that you are draining the breast as completely as possible. Make sure not to stop pumping before the milk stops flowing. In addition, continuing to pump after the milk slows to a trickle can be helpful. Remember, breastfeeding works on supply and demand, and continuing to pump for few minutes after the milk has slowed significantly helps to signal your body that it needs to produce more milk.
  • Try using breast massage and compressions. The use of breast massage and compressions can be helpful in removing more milk from the breast when you breastfeed or pump. The more milk that is removed, the more you will make. For more information, see Nancy Mohrbacher’s article To Pump More Milk, Use Hands on Pumping. While it specifically addresses pumping milk for premature babies, the techniques translate nicely to pumping for full-term and older babies and can be used in feeding at the breast, as well.
  • Keep an eye on your stress level. Stress can negatively impact your milk supply and inhibit your letdown. Take some time to relax. Have a warm bath, let dad or a friend care for the baby, even for twenty minutes, so that you can do some deep breathing, yoga, or take a walk around the block, lie down and close your eyes, or whatever is a good stress buster for you. Make sure to get adequate sleep, napping whenever your baby does, as well.
  • Enjoy some snuggly time with your baby. Spending some time skin-to-skin can help boost your milk supply. Undress baby down to her diaper and hold her close to you. Take the opportunity to relax, take a break, and snuggle up while she naps and you catch up on a great book or those DVR episodes of your favorite shows that you’ve been saving.
  • Eat well and drink plenty of water. While there is not a great deal of concrete evidence that caloric intake or even intake of water has a direct effect on milk supply, it is important to nourish your body to make sure you are able to nourish your baby. Many mothers report feeling thirsty when they nurse and have water or their favorite non-caffeinated beverage handy.
  • Avoid supply killers. Some medications can be particularly detrimental to your milk supply, such as hormonal birth control and decongestants. In addition, caffeine, alcohol, and smoking can all reduce production. Even some herbs like sage, peppermint, and parsley, when taken in large quantities, can affect production. If you are not sure whether a medication you are taking can reduce supply, you may want to visit the National Institute of Health’s LACTMED database.
  • Keep in mind that none of these solutions will work overnight, and none are magic wands. Allow time to determine if a given tactic is making a difference. When you have questions, find a breastfeeding support person who can help counsel you through the process.

    Finding a Breastfeeding Support Person Breastfeeding USA has counselors in many areas who are volunteers, eager to help with most normal breastfeeding issues. To find the Breastfeeding USA Counselor nearest you, visit https://breastfeedingusa.org/content/article/find-breastfeeding-counselor.

    Occasionally, a breastfeeding question or concern is more complex or requires evaluation for potential medical intervention. In these cases, you may want to seek an International Board Certified Lactation Consultant (IBCLC). You can find the IBCLC nearest you at www.ilca.org.

    Additional links to breastfeeding professionals and volunteers can be found at http://kellymom.com/bf/concerns/bfhelp-find/.

    If You Decide to Use Galactagogues
    Galactagogues really may work for some moms, and you may decide to use them but, hopefully, not as a first line of defense. They can simply mask the problem instead of offering a solution. Not all galactogogues are the same. An IBCLC can help you find the reason why you are not making enough milk. Whenever taking a medication or supplement, be certain to consult with a health-care professional regarding the safety of the medication, making sure to disclose any other medications you may be taking to avoid negative drug interactions. If you decide to consume foods or drinks that you have heard increase your supply, be sure to do so safely, and don’t expect a miracle from a bowl of oatmeal, a “lactation cookie,” or a sports drink.

Copyright June 2015 Breastfeeding USA. All Rights Reserved.

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

Research and Evidence-Based Mother-to-Mother Support

“Breast is best” is a standard advocacy mantra, but what does the research and evidence actually say? In reality, breastfeeding is just normal - it doesn’t confer magical properties and make babies and mothers superhuman. What research actually shows is that when a baby isn’t breastfed, the baby is at higher risk for acute and chronic health conditions.1

It can really shake one’s confidence to read headlines like “Is Breast Truly Best?”2 As Breastfeeding USA Counselors, we agree to provide evidence-based breastfeeding information and support, and to promote breastfeeding as the biological and cultural norm, but this article questions the importance of breastfeeding. Here are some things to consider when using research:

  1. Use systematic reviews or meta-analyses: This type of research evaluates multiple sources, excluding research with poor methodological study design. A great example of this type of research is the Agency for Healthcare Research and Quality (AHRQ) study by Ip, entitled “Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.”4 Let’s look at the research on ear infections (otitis media) from the AHRQ report. A breastfed infant has a 44% chance of getting an ear infection in the first year. A formula-fed infant has an 88% chance of getting an ear infection. It is the act of formula feeding that doubles the risk of ear infections.

    Another important example from this research concerns mother’s weight loss. Many mothers are told that if they breastfeed, they will lose more weight. The research is actually inconclusive on this statement, because there are so many confounding variables that could impact postpartum weight loss. We do know that mothers burn additional calories while they are breastfeeding (see AAP Policy 5 statement), but those calories can easily be undermined by excessive eating and not exercising.
    At the end of this article, you will find more examples of this type of research.

  2. The Breastfeeding USA Statement on Breastfeeding6 is research and evidence based.
  3. Here are some talking points to consider for the article “Is Breast Truly Breast”:
    * The researcher is a sociologist and did an excellent job of analyzing data from a large ongoing national survey. The data was collected during a time when exclusive breastfeeding in the US was low.
    * The study confirms the benefits of breastfeeding across a broad population, identifying that children who were breastfeed fared best on 10 out of 11 measures.
    * The study continues to state that when testing within families, the benefits of breastfeeding were not statistically significant. (This doesn’t mean that it isn’t good, just that they didn’t find a statistically significant difference in the population measured.)
    * The study’s definition of breastfeeding is poorly defined.
    a. Any child who was breastfeeding for any duration is included in the breastfeeding measure, regardless of exclusivity or duration.
    b. The question of duration of breastfeeding is not indicated clearly in their study. Data on the number of breastfed children appear to be missing.
  4. The study’s limitations indicate that there may be retrospective bias that may alter results – this is stated in the self-evaluation of the research.
  5. Public health recommendations are based on the broad benefits of a health behavior, not individual family benefits. (Statistical rather than anecdotal evidence.)
  6. Breastfeeding is the normative feeding behavior, with clear biological benefits, especially during the infant years. This study did not take into account those important benefits.
  7. The author’s main goal seems to be to advocate for better resources for mothers who typically have lower breastfeeding rates. They seem to assume that advocating and supporting breastfeeding are somehow incompatible with other initiatives, such as improving child care access and improving maternity leave. Breastfeeding advocacy is completely compatible with other social initiatives that support mothers and healthy child development.
  8. The US Surgeon General’s Call to Action to Support Breastfeeding 7 specifically addresses mothers' and babies' child care and employment needs, with corresponding research.
  9. The bottom line on the evidence, as stated by the US Surgeon General, is that “everyone can make breastfeeding easier.”

    Supporting mothers is the most important goal!

    References
    1. Stuebe, The Risks of Not Breastfeeding, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/

    2. “Is Breast Truly Best?” Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons” by Cynthia G. Colen, David M. Ramey. http://ybreast.com/comingsoon/wp-content/uploads/2014/03/Sibling-Study.pdf

    3. Breastfeeding USA Purpose Statement https://breastfeedingusa.org/content/purpose

    4. Ip, AHRQ, http://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf

    5. American Academy of Pediatrics Policy Statement http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011...

    6. Breastfeeding USA, “Statement on Breastfeeding”. https://breastfeedingusa.org/content/article/statement-breastfeeding

    7. US Surgeon General’s Call to Action, http://www.surgeongeneral.gov/library/calls/breastfeeding/index.html

Copyright Breastfeeding USA. All rights Reserved. August 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

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