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
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.
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."
- PR1. Cleft Palate Foundation, For parents of newborn babies with cleft lip/cleft palate (accessed october, 2013) http://www.cleftline.org/parents-individuals/publications/fact-sheets/
- PR2. Cleft Advocate http://www.cleftadvocate.org/
- PR3. Cleft Lip and Palate Foundation of Smiles www.cleftsmile.org/
- PR4. Cleft Lip and Palate Breastfeeding Discussion Group https://www.facebook.com/groups/339242706210018/
- PR5. Baby centre cleft moms https://www.facebook.com/groups/425825524141451/
- PR6. Exclusive expressing/pumping https://www.facebook.com/groups/19128555821/
- Farrow, A, 2013, One cleft is not like another, (accessed October 2013) http://cleftlipandpalatebreastfeeding.com/2013/08/one-cleft-is-not-like-...
- 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
- Farrow, A., What to expect, http://cleftlipandpalatebreastfeeding.com/2013/07/what-to-expect/ (accessed October 2013)
- Grady,E,. 1983, Nursing my baby with a cleft of the soft palate, Schaumburg, Illinois, La Leche League International, 1983 (out of print)
- Cleft palate breastfeeding (video) http://www.youtube.com/watch?v=BpqqYQlKDeA (accessed October 2013)
- Cwir, J. (ed), 2013, I wish I’d known….how much I’d love you!’, CreateSpace Independent Publishing Platform
- 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
- 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)
- West, D., Maximizing a Mother’s Milk Production Capability, http://www.breastfeedingconferences.com.au/search_results.php?cx=0074617... (accessed October 2013)
- West, D. and Marasco, L., (2009). The Breastfeeding Mother's Guide to Making More Milk. New York, NY: McGraw Hill.
- Cotterman, J., Reverse Pressure Softening http://www.breastfeedingmadesimple.com/SimplerRPSsheet2.doc (accessed October 2013)
- 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
- The Americleft Outcomes Project http://www.acpa-cpf.org/research/the_americleft_outcomes_project/
- 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)
- The World Health Organization's infant feeding recommendation http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/
- 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
When I was pregnant, there were many decisions to be made about how to balance the needs of a new baby while continuing an earth-friendly lifestyle. From cloth diapers to organic cotton baby clothes and non-toxic toys, many small choices were made with the bigger picture in mind. For many reasons, I chose to breastfeed — a decision that impacted me, my baby, and Mother Earth!
Packaging: Human milk is ready to serve in its original container and is already at the perfect temperature! If every child in America were bottle-fed, almost 86,000 tons of tin would be needed to produce the 550 million cans required for a year’s worth of artificial formula. Plus, bottles and nipples are made from glass, rubber, plastic, and silicon; most are not recyclable.
Waste: Formula packaging and shipping boxes contribute to the waste in landfills. If a baby goes through eight 12-ounce cans of formula per month, 96 empty containers are thrown away before his first birthday. Plus, when breastfeeding, there’s no worry about BPA-lined bottles and cans, or formula recalls for contaminants.
Production: Manufacturing formula requires huge dairy farms, milking machines, cattle feed, manure disposal, factories, packaging, and shipping with all the associated costs. Breastfeeding requires none of these, and is free. Substituting cow’s milk for human milk destroys the water, land, and air. Waste from cattle farms pollutes rivers and groundwater. Cow flatulence releases methane, which may contribute to the destruction of the ozone layer. It would take 135 million lactating cows to substitute the breast milk just of the women of India.2 That many cows would require 43% of the surface of India to be devoted to pasture.
Fewer tampons and diapers: Women who practice total, unrestricted breastfeeding average 14 months without menstruating. This helps with child spacing, and reduces the need for sanitary products. And because formula is absorbed slowly and inefficiently, babies receiving formula excrete more and require more diapers.
Breastfeeding is a natural, renewable resource making it the perfect environmentally-friendly choice.
1. Happy Earth Day http://normaritter.blogspot.com/2009_04_01_archive.html
2. The Ecological Impact of Bottle Feeding, by Andrew Radford, Baby Milk Action http://www.reducepackaging.com/impact-bottlefeeding.html
3. Breastfeeding; The Eco-Friendly Way to Feed Your Baby www.gogreenstreet.com/%20breastfeeding-the-eco-friendly-way-to-feed-your...
4. Breastmilk: the perfect renewable resource http://www.infactcanada.ca/ren_res.htm
Copyright Breastfeeding USA 2013. All rights Reserved
The season of sneezes and sniffles is upon us, and many moms and babies are likely to catch colds or the flu. Evidence shows that breastfed babies have considerable protection from such illnesses, and when they do become ill, relief can come directly from mother’s milk.
Colostrum, the early milk a breastfed newborn receives for a few days after birth, contains highly concentrated antibodies that protect against many diseases. Mature milk continues to protect infants from many diseases and strengthens the immune system. Babies who are not breastfed have a higher risk of contracting bacterial infections, such as E. coli and salmonella; viral infections, such as influenza and rotavirus; as well as parasites.
One of the most amazing qualities of human milk is how it adapts. As mother and baby are exposed to bacteria and viruses, milk includes antibodies specific to those antigens. It also contains more general disease-fighting substances that provide help in preventing many common illnesses. A mother will pass antibodies to her baby through her milk, which can actually destroy bacteria in the infant’s gastrointestinal tract before they have a chance to make baby sick. Ear infections and allergies occur more commonly in babies who are not breastfed.
When baby does get sick, one of the best things a mother can do is keep breastfeeding. Babies who are ill need to keep up their fluid intake, especially if there is vomiting or diarrhea. Breastfeeding should continue as usual, and there is rarely a need to replace or supplement human milk with water, juice, or Pedialyte. If the baby is too sick to breastfeed, expressed breast milk can be given from a cup, bottle, syringe, or eyedropper.
If baby’s nose is too stuffy to breastfeed, suggestions include:1,2
- Run a cool mist vaporizer near where baby sleeps.
- Take baby into the bathroom after you have filled the room with steam from the shower.
- Add a pinch of salt to a cup of warm tap water and squirt a few drops into baby’s nostrils using an eyedropper (or use a commercial saline nose spray).
- Use a nasal aspirator to suction mucus from baby’s nostrils. Squeeze the bulb first, insert the tip into baby’s nose, and then slowly release the bulb so the suction gently pulls out excess mucus. Mom’s health-care provider can show her how to use a nose spray or do nasal suctioning, if she hasn't already been instructed in these techniques.
Here is a video demonstrating nasal suctioning.
When mother is sick, there are a few steps she can take to reduce the chance of passing the illness to her baby, such as washing her hands frequently, and trying not to cough or sneeze on the baby while nursing or whenever baby is close.
Nursing mothers should be cautious of taking over-the-counter medications while breastfeeding. Decongestants can cause babies to be irritable, and antihistamines can make them drowsy.1 Pseudoephedrine has been shown to suppress milk supply. 2 For more information about medications for use in breastfeeding mothers, visit LactMed.
1. Gaskin, Ina May. Ina May's Guide to Breastfeeding. NYC: Bantam, 2009.
2. Lauwers, Judith, and Anna Swisher. Counseling the Nursing Mother. Sudbury. MA: Jones and Bartlett, 2011.
Copyright Breastfeeding USA 2014. All rights are Reserved.
“I can’t believe she’s doing THAT in public!” could be a comment on a multitude of situations. Unfortunately, it’s often used when a mother is seen nursing her child outside of the home. Breastfeeding in public is a top concern of many nursing mothers - they are worried about what people will say, whether they will be asked to leave a public place, or afraid they’ll become a headline news story! Why and when did breastfeeding in public become cause for public outcry? What is all the fuss about?
Nursing in public seemed to be a non-issue in colonial America. Our foremothers were expected to maintain a busy household, which included feeding the baby, and breastfeeding in the market or other public areas was not a cause for uproar. At that time, breastfeeding was the only way to feed a baby, either by the natural mother or a wet-nurse. The Puritans believed breasts were created for the nourishment of children and strongly encouraged women to nurse their own babies. 1 Breastfeeding in public was commonplace for colonial women because they lived in a society that supported breastfeeding.
What happened to change American society's views on nursing in public? Society’s outlook on breastfeeding began to change as the modern feeding bottle and nipple were invented, and commercially-created infant formulas became more accepted in the early 20th century. Scientists began analyzing components of human milk; this data also spurred the search for a chemically-modified animal milk that would closely resemble human milk. 2
Breastfeeding was dealt a double whammy in the early 20th century. As World War II raged on, women were needed to fill jobs left empty by men going off to war. Breast pumps were primitive in design, there were no laws that allowed women time to express milk while at work, and wet nursing went out of style. What was a mother to do? At this same time, large-scale manufacturing made infant formula easier for mothers to access.3 Formula manufacturers cultivated relationships with physicians, which led to physicians promoting formula use as a safe and accepted way to feed baby. With so many factors suppressing breastfeeding, it isn't surprising that breastfeeding rates began to decline sharply after World War II.
As infant formulas became more accepted in society, they became more popular, and bottles became commonplace. Breastfeeding rates declined steadily until the 1970s. With fewer women breastfeeding, even fewer were seen breastfeeding outside their homes. The sight of a woman nursing her child lost its normalcy and was replaced by bottle feeding. Consequently, when a woman is now seen nursing her baby, it feels alien and creates discomfort in many people. The rise of direct-to-consumer marketing and the use of women and breasts to sell products also contributed to this unfamiliarity with breastfeeding. In our society, breasts are often used to sell cars and beer; when they are seen being used for their biological purpose, it creates conflict for some people.
One major conflict is the so-called “Mommy Wars,” of which breastfeeding versus formula feeding is a major battleground. Influenced by the formula companies’ devotion to shareholder profit instead of mother support, the Mommy Wars play on a mother’s insecurity and fear that she is “ruining her child” or “doing it wrong.” If a woman had a prior negative breastfeeding experience, seeing a woman breastfeed in public might trigger upsetting emotions.
Today, nursing in public, or NIP, has become a hot-button issue. Women are told to cover up, feed in a bathroom, feed somewhere else, or are subjected to the stares of an uninformed public. Concerned breastfeeding supporters descend on businesses to hold nurse-ins. There is a NIP hotline sponsored by the nonprofit organization, Best for Babes, that collects stories of women being harassed while nursing in public and offers support and encouragement.4 Women can even take a 7-day e-course on how to nurse in public.5 Nursing in public is a popular topic of discussion at Breastfeeding USA Chapter meetings.
In many aspects, the law is on the side of a breastfeeding mother when nursing in public. At the federal government level, Public Law 106-58, Section 647 states: “Notwithstanding any other provision of law, a woman may breastfeed her child at any location in a Federal building or on Federal property, if the woman and her child are otherwise authorized to be present at the location.”6 Laws vary by state and most states have have laws that specifically allow women to breastfeed in any public or private location. Find up-to-date information about the breastfeeding laws in your state at the National Conference of State Legislatures: Breastfeeding Laws
Knowing all this, how can we normalize breastfeeding in public? Here are some ideas:
- Know the breastfeeding laws in your state and educate your staff.
- If a staff member treats a breastfeeding mother inappropriately, promptly apologize to the mother and give that staff member the training they need.
- If possible, have available areas where breastfeeding mothers can feed privately, if they desire. A bathroom does not qualify as a nursing area, but a dressing room might!
- When you see a breastfeeding mother, offer a smile, a thumbs up, or some words of encouragement; remember that staring might make her uncomfortable.
- If seeing breastfeeding makes you uncomfortable, look the other way.
- Some people are concerned about children seeing babies breastfeed. If your child sees a baby at the breast and asks you about it, simply say, “That mommy is feeding her baby.” Children generally don’t need or want a long explanation when a short one will suffice.
- Find what is comfortable for you. Pamela prefers to cover and be somewhat discreet, while Katie pops her baby in the carrier to feed and goes on with her day. The point is, figure out your nursing-in-public style: Cover or no cover? Park bench or your car? Dressing room or front of the store? Feeding in the carrier/sling? There are many ways to customize breastfeeding in public to fit your comfort level.
- Practice at home in front of a mirror or a supportive person before you go out! This will help you gain the confidence you need to feed your baby when you are away from home.
- Find support. If you’re nervous the first few times you go out, take an encouraging friend. Talk to your partner about your commitment to breastfeeding and how to help you in public.
- Know your rights. It may be helpful to carry a copy of your state’s breastfeeding laws to help educate anyone who questions you about nursing in public.
- Support other mothers. One way to normalize breastfeeding in public is to stop buying into the idea that mothers are in competition with each other. Instead of criticizing a woman for “having her breasts out,” realize that she is just trying to feed her baby, who otherwise could be screaming. Public breastfeeding isn’t meant to “show off” breastfeeding skills; it’s simply the reality of daily life and nourishment for your baby.
1. Mays, D A (2004). Women in Early America: Struggle, Survival, and Freedom in a New World. Santa Barbara, CA: ABC-CLIO.
2. Stevens, E. E., Patrick, T. E., and Pickler, R. (2009). A History of Infant Feeding. Journal of Perinatal Education, 18, 32–39. doi: 10.1624/105812409X426314
3. Weimer, J.P. (2001). The Economic Benefits of Breastfeeding: A Review and Analysis. Washington, D.C.: U.S. Department of Agriculture. http://www.ers.usda.gov/media/329098/fanrr13_1_.pdf
4. Hickman, M. (2011). Announcing 1-855-NIP-FREE: the Best for Babes “Nursing In Public” Harassment Hotline. Retrieved March 11, 2013 from http://www.bestforbabes.org/announcing-1-855-nip-free-the-best-for-babes....
5. Theuring, A, 2012. Become a Badass Public Breastfeeder in 7 Days. Retrieved January 27, 2013 from http://web.archive.org/web/20130516015708/http://gentleparentinfo.com/Ba... .
6. United States Breastfeeding Committee. (n.d.). Existing Legislation. Retrieved March 11, 2013 from http://www.usbreastfeeding.org/LegislationPolicy/ExistingLegislation/tab....
Copyright Breastfeeding USA 2014. All rights reserved.
When breastfeeding, inevitably the topic of weaning comes up. “How long will you go for?” “What’s your goal?” “Are you going to nurse until baby is ready to stop?” “You’ll stop before he goes to college, right?” The answers to these questions (except the last one!) are not so simple. Breastfeeding is a relationship between two people - mother and baby. As both evolve and grow throughout the relationship, so do ideas about weaning.
There is usually a time frame involved when discussing the duration of breastfeeding: exclusively at least until about six months of age, then combined with complementary foods to one year and beyond(1) or to two years and beyond (World Health Organization (2). Right from the start, the idea of an end date is planted in the minds of mothers. Often, once mothers reach these scheduled milestones, they find they enjoy breastfeeding too much to stop and decide to keep going. Rarely does a mother say, “I’ll breastfeed until I’m ready to stop.” When this situation arises – that mom is ready to stop breastfeeding but baby isn’t quite there yet – complicated emotions may develop.
What is weaning?
Depending on culture, weaning may be defined as introducing foods other than human milk to a baby or stopping breastfeeding entirely(3). For the purposes of this article, we will discuss weaning as ending all feeding at the breast.
Natural weaning, sometimes called child-led weaning, occurs when the child no longer has an emotional or nutritive need to breastfeed.(4) This usually doesn't occur before 18-24 months of age. Letting the child set the pace for weaning allows him to reach the developmental milestone of weaning on his own timeline. Though the child may ultimately decide when the breastfeeding relationship is over, this does not mean the mother sits by passively. As with any relationship, there is an element of give-and-take in the breastfeeding relationship. Mothers can set limits as the child grows older, such as only nursing at certain times of the day or asking the child to wait until mom is finished with a meal or task. Natural weaning is an intricate dance between mother and child that can take months or sometimes even a year or more to play out.
Mother-led weaning happens when a mother actively encourages weaning before a child is naturally ready. This may be done by increasing the use of a bottle or cup, offering food/drink besides human milk, or limiting nursing.
When NOT to wean
It’s important to note that there are several common reasons mothers give for weaning that may not be in the best interests of both mother and child. These include:
- Pressure from others: Friends and family will have their own opinions about when a mother should wean her baby. They are not a part of the nursing relationship and shouldn't be given power in this decision. If you’re finding it difficult to handle the opinions of friends and family, you may be able to find mother-to-mother support through a Breastfeeding USA Counselor.
- Misinformation: Some women are told their milk isn't nutritional after the baby reaches a certain age. Does broccoli stop being healthy after a certain age? No, and neither does your milk. Other myths told to mothers include that she’s only doing it for herself; the child doesn't need breastfeeding after a certain age; breastfeeding past a certain age is bad for the child; or that breastfeeding is the reason she is [insert problem/ailment here]. Talking to a breastfeeding counselor about nursing concerns can help women from prematurely weaning due to faulty information.
- Pregnancy: It is generally considered to be safe to breastfeed while pregnant. According to Dr. Bob Sears, breastfeeding during pregnancy may not be safe for “moms who have a history of miscarriages or preterm labor (labor beginning before 37 weeks gestation) with previous pregnancies (5).”
- Nursing strike:Children who self-wean rarely stop abruptly. If your child suddenly refuses to nurse, chances are it is a nursing strike, rather than weaning.
- Distractibility: Older babies and toddlers become fascinated with the world around them and will sometimes be too distracted to nurse. This does not mean they don’t need the breast anymore – it just means they may need some help focusing on the task of nursing for a while. Moms can help their babies focus by nursing in a quiet, darkened room; trying a new position; or wearing a “nursing necklace” that gives baby something to play with while nursing.
- Going back to work or school: Even if you aren't able to express milk while away from your child, this does not have to mean the end of breastfeeding! You can still breastfeed during the times you are with the child. When mom is away during the day, some babies do what is called reverse cycle breastfeeding: nursing frequently at night and less frequently during the day. Continuing to breastfeed during those times may help both you and baby reconnect after you have been separated. For more information on how to express at work or school, check out the “Expressing Your Milk” section of Breastfeeding USA at https://breastfeedingusa.org/breastfeeding-information.
One important reason that a mother might begin the weaning process is that her feelings about breastfeeding have changed. Amber recalls, “One day I realized that I wasn't enjoying breastfeeding anymore. My nipples had become very sensitive, which made sex difficult to enjoy; I wanted to lose weight but was fearful that dieting or exercising too much would affect my milk; I was tired of only being touched when someone wanted something from me; I was tired of being woken up in the night and early in the morning; I was tired of having to sleep with a bra on . . . but I was determined to finish out my daughter’s first year and avoid putting her on formula.”
Brandie notes that when she reached her goal of one year, she was “just plain ready” to wean, but that “it was an emotional time and a long process that dragged on for months. I think I was ready to wean before my son was, but it was a two-person effort. We didn't successfully wean until he was ready.”
If a mother starts to have negative feelings about breastfeeding, it’s important to explore them. Many women will try to stuff them away, afraid of being labeled selfish or a bad mother. However, keeping those feelings in the dark only allows them to grow stronger.
Amber continues: “I pushed through my growing aversion to being touched and continued to breastfeed my daughter. I started to feel some resentment towards her, especially when she would prolong the experience by looking around like she was done, then fussing if I put my breast away, and I hated when she would reach her little hand over to my other nipple and remind me that she needed her nails cut. My resentment eventually turned to fear: would this experience affect my desire to breastfeed other children?”
The complicated emotions of weaning
The decision to wean is not an easy one. It can help if a mother can identify what she is feeling and then accept those feelings without judgment. Disliking or resenting breastfeeding does not make a woman a bad mother. Next, it might be helpful to talk about these emotions with a breastfeeding counselor or a trusted health-care professional. The decision to wean isn't one that should be made lightly, and talking about it with someone knowledgeable about breastfeeding can help a mother make an informed decision. It’s much easier to continue breastfeeding when you are unsure, than it is to stop and then try to relactate later.
When a woman decides to stop breastfeeding, she needs to know about the physical aspects to watch out for: engorgement with an increased risk of clogged ducts/mastitis. But many mothers are surprised at the intense emotions that can accompany this change. Some mothers, like April, report a mixture of emotions when their child doesn’t need to nurse anymore. A woman may feel nostalgic, sad, or depressed when breastfeeding ends, even if she is the one who made the choice to stop.
Hormonal changes play a part in this. Breastfeeding increases the levels of both prolactin and oxytocin, hormones that create feelings of well-being, calmness, and relaxation in most women. As weaning occurs, these hormone levels will drop, often producing emotional effects. Gradual weaning will help prevent a sudden drop in levels. Oxytocin levels increase during cuddling, hugging, and kissing - all activities that should be encouraged during the weaning process.(6)
In addition to hormonal influences, mothers may feel sadness because weaning marks a change in the mother-child relationship. Breastfeeding is one thing that only the mother can offer, and weaning is an end to that part of mothering. It’s common to miss the connection that breastfeeding provided. Sometimes, if mother-led weaning goes “too easy,” a mother can feel hurt by the child’s lack of concern for stopping nursing. Lisa shares, “I wanted to wean but still felt so guilty and sad. The first full two days that he didn't nurse, I cried all day!” Weaning may trigger a depressive episode in some women, especially if there is prior or underlying depression.(7)
Along with sadness comes the guilt. When a mother decides to stop breastfeeding, she knows she is taking something important from her child. There are two people in a breastfeeding relationship, but it is extremely difficult for most mothers to put their needs ahead of the needs of their baby. The importance of breastfeeding cannot be overstated, but if it is beginning to contribute to negative emotions in the mother-child relationship, then a mother must be empowered to explore these emotions without fear of judgment.
Tips for healthy weaning
If you are thinking about weaning, be prepared for the mélange of emotions that may occur. There are ways you can make this a smoother transition for both you and your child.
- Wean gradually. Drop one feed at a time, with plenty of time in between. Sara estimates that her weaning process took about 4 months. Weaning gradually will protect mother from physical problems, as well as give the child ample time to adjust to the change. Also, if you start dropping feeds and then decide you aren’t ready to fully wean, you’ll be able to continue breastfeeding more easily.
- Find new ways to comfort your child. Your child needs emotional support from you; nursing was one way to provide that. Without nursing, you’ll need to find other ways to comfort your child. Cuddling, hugs, and singing are all good ways to offer comfort without the breast. Enlist the help of your partner or family member, if available, to give your child more attention and skin-to-skin contact.
- Talk to someone. If you are struggling with depression, sadness, anxiety or other strong emotions, find a trusted confidant such as your partner, another family member, a close friend, or a Breastfeeding USA Counselor. If your symptoms persist, consider seeing a health-care professional for additional support.
- Take care of yourself. Eat a healthy, well-balanced diet. Try to get enough sleep. Get outside to enjoy nature. Physical activity is a great way to improve mood through the release of endorphins. Do something special and fun with your child, such as taking walks, going to the park, or another activity your child enjoys.
- Commemorate your breastfeeding experience, especially with an older child, through a weaning ceremony. The Leaky Boob, a popular breastfeeding blog, has some great examples of weaning ceremonies. Writing your nursing story, getting body art, buying/making a special piece of jewelry, and performing ceremonies/rituals are all ways mothers have honored the end of their breastfeeding relationship.
No matter how weaning begins and ends, child-led, or mother-led, or a natural combination of both, it is often a process of great significance for all involved, including other family members. Every child weans at some point. For a fulfilling breastfeeding relationship, weaning needs careful thought, consideration of needs, open discussion, and caring responses.
1. American Academy of Pediatrics. (2012). AAP Reaffirms Breastfeeding Guidelines. Retrieved from http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirm...
2. World Health Organization. (2013). WHO | Breastfeeding. Retrieved from http://www.who.int/topics/breastfeeding/en/
3. Greiner, T. (1996). The Concept of Weaning: Definitions and Their Implications. Journal of Human Lactation, 12, 123-128.
4. Bonyata, K. (2011). Do Babies Under 12 Months Self-wean? Retrieved from http://kellymom.com/bf/normal/babyselfwean/
5. Sears, Bob. (2013). Breastfeeding While Pregnant. Retrieved from http://www.askdrsears.com/topics/breastfeeding/special-situations/breast...
6. Bonyata, K. (2011). Comfort Measures for Mom During Weaning. Retrieved from http://kellymom.com/ages/weaning/wean-how/weaning_mom/
7. Sharma, V. and Corpse, C. S. (2008) Case Study Revisiting the Association Between Breastfeeding and Postpartum Depression. Journal of Human Lactation,24(1),77-79.
© Copyright Breastfeeding USA, Inc. 2013. All rights reserved.
One of the most common health concerns for women of childbearing age is an autoimmune disorder. According to the American Autoimmune Related Disorders Association1, authorities estimate that around one in five people—two thirds of them women—are living with an autoimmune disorder in the United States. Unfortunately, autoimmune disorders are not as rare today as in previous generations1. The reason for the increase in frequency of autoimmune disorders is unknown. Mothers with autoimmune disorders face unique challenges with regard to pregnancy and breastfeeding. This subset of mothers is often overlooked in standard parenting literature. This is a brief introduction to autoimmune disorders to give a better understanding of the issues surrounding the intersection of autoimmune disorders and motherhood.
What is an autoimmune disorder?
The immune system is responsible for fighting off infections as well as identifying and destroying abnormal cells, like cancer cells2. The ability to correctly identify normal “self” cells and invading microorganisms or abnormal cells as “non-self” cells is crucial to normal, correct functioning of the immune system. In an autoimmune disorder, the immune system gets ‘confused’ and is not able to tell the difference between normal and abnormal “self” cells2. This confusion means that the body begins to attack itself, causing an astonishing array of symptoms and diseases, ranging from relatively mild to life-threatening. In fact, autoimmune diseases are counted in the top ten causes of death for women under 651. No one knows what causes this confusion, except that these disorders are caused by a combination of genetic influence and environmental, not any one trigger2.
What are some examples of an autoimmune disorder?
There are over 100 different kinds of autoimmune disease1. Here are some examples:
- Type 1 diabetes: the immune system attacks the pancreas or insulin receptors (sometimes both), resulting in the inability to make and use insulin3.
- Hashimoto’s thyroiditis and Graves’ disease: conditions in which the immune system attacks the thyroid gland, resulting in under or overproduction of thyroid hormone2. Thyroid hormone is responsible for a whole host of functions, including metabolism and neurological development in the fetus and newborn.
- Ulcerative colitis and Crohn’s disease: collectively referred to as “inflammatory bowel disease”. The immune system mistakenly attacks the digestive system, causing painful abdominal cramps, digestive problems, and sometimes nutritional deficiencies4.
- Multiple sclerosis: the target is the nervous system. Interruptions in nerve transmissions result in a variety of symptoms, including numbness, pain and paralysis1. It is usually intermittent at first and often progresses to permanent disability5.
- Rheumatoid arthritis: generally results in the body attacking the joints, causing joint deformation, debilitating pain, and stiffness,2.
- Systemic lupus erythematosus (lupus): any system of the body may be attacked, from the heart and lungs to kidneys, skin, digestive or nervous system, causing damage and malfunction to that system2.
How does life change with an immune disorder?
Life with an autoimmune disorder varies with the disorder. Usually, a woman who looks perfectly healthy will start having vague symptoms that come and go and are hard to describe1. Often, she will have an idea that something is wrong, but because it is hard to describe the symptoms, she will put off talking to her doctor about it until they start to affect her everyday living. Thus begins the diagnostic odyssey.
Diagnosis with an autoimmune disease can be a long, difficult process. While some are able to get a diagnosis within weeks of the onset of symptoms, for others the process takes years of frustrating visits to numerous doctors. It isn't uncommon for sufferers of some diseases to be incorrectly labeled as drug seekers, chronic complainers, or worse, told that the disease is “all in the head”1. Treating the disease is not always easy, either. Some diseases simply require replacement of hormones that aren't being produced, like autoimmune hypothyroidism. Others, like lupus, may require life-long suppression of the immune system, along with management of the many symptoms that result from organ damage2. Finding the right medications to manage symptoms is an adventure in and of itself, with scary-sounding side effects like the possibility of cancer or heart problems. It is not uncommon for people with autoimmune disorders to go months or years at a time with minimal or no symptoms, followed by what’s called a “flare up,” an exacerbation of the disorder when the symptoms get very difficult to deal with and may keep a person bed or house-bound until it recedes. Others may not get a break, causing them to be unable to keep a job or manage around the house without help.
My own journey with autoimmune disease began as a postnasal drip and headaches when my first daughter was around a year old. Then a few months later, a vague, aching pain began, deep in my leg muscles at night. Sometimes I would get tingling nerve pain and my arms or legs would “fall asleep.” At first, the symptoms weren't too bad, and I passed it off as aches from exercising, bad posture, and allergies. By the time she was two, I realized that not only were the symptoms getting worse, keeping me from being able to sleep at night, but the symptoms didn't correlate with exercise or anything else. They were also starting to affect my day-to-day living, interfering with my ability to attend school, go to social engagements, and even interact with my family. Over the counter medications didn’t help, so I sought treatment, but was unable to find a doctor who would help. After many doctors visits, trials with different drugs and nasal sprays were ineffective. I just learned to cope. Eventually, when my daughter was four, I found a rheumatologist who diagnosed me with “undifferentiated connective tissue disorder” because although my lab results indicated something autoimmune, my symptoms didn't fit anything on his list. My symptoms finally became manageable with the drugs he prescribed. Because my disease wasn't “bad enough” to affect anything vital, however, getting a precise diagnosis was not a priority.
In contrast to my years-long (and still incomplete) journey toward diagnosis, a friend of mine, Joanna, started having symptoms one November and was diagnosed by the next month with ulcerative colitis. This disease is particularly difficult to deal with when it flares. Joanna describes what it’s like: “I get lots of pain, cramping and bloody stool, with times of flare ups which can keep me on the toilet for over an hour at a time and many times through the day and night. I get very tired because of dealing with the pain and being on the toilet, and I worry about taking care of my daughter and getting her to school on time and being able to pick her up. Leaving the house can be scary just for things like grocery shopping; it can take me much longer than everyone else because I may have to use the restroom 2-5 times while in the store. The pain can be very severe. There were times when I was in so much pain I was trying not to scream; it was like giving birth multiple times a day, where [her husband] was threatening to call 911 and send me to the hospital.”
What do these changes mean for women of childbearing age?
The hormonal activity inherent in menstrual cycles is believed to be the reason women of childbearing age are at increased risk of autoimmune disease7, 8, 9. Years ago, women with autoimmune conditions were simply advised not to get pregnant (5, 11). With modern medicine, doctors and researchers are finding that this advice is outdated5-7, 10, 11. Unfortunately, many women are still incorrectly advised that their condition is a complete contraindication to pregnancy and breastfeeding.
When women with autoimmune disorders want to get pregnant, they are advised to plan pregnancies carefully. They are told to wait until they are on a pregnancy-safe medication, or to wait a certain number of months after stopping a medication that is expected to cause birth defects. They may be told to wait until their disorder has been in remission, and they can find a good team of doctors to take care of them10.
Can a woman with an autoimmune disorder safely carry her baby to term and breastfeed?
Although many doctors mistakenly tell women that it is not safe to get pregnant or breastfeed simply because of their diagnosis, this is not evidence-based advice. Some doctors insinuate or outright tell mothers that if they breastfeed, the antibodies in their system will get into the baby and cause an autoimmune disease in the breastfed infant; this is not true12. Other health-care workers may incorrectly tell women that they won’t be able to continue taking the drugs that control their disorder if they choose to get pregnant or breastfeed. Some women with advanced disease states may be counseled against pregnancy due to symptoms such as uncontrollable high blood pressure or kidney damage. According to experts well-versed in current research, a diagnosis of an autoimmune disorder in and of itself is never a contraindication to pregnancy or breastfeeding10. In addition, current research indicates that many drugs previously believed to be unsafe for pregnant or nursing mothers are, in fact, no more likely to cause birth defects than other drugs considered safe5-7, 11, 13, 15. Most women with autoimmune disorders can have a baby without serious side effects, though some diseases require careful monitoring,7-10. In fact, for some disorders, like multiple sclerosis, rheumatoid arthritis, and inflammatory bowel disease, the progression of symptoms can be slowed or stalled by pregnancy and exclusive breastfeeding6,8,9,15,16. This is thought to be associated with the hormonal shift that accompanies lactational amenorrhea7,8,9,15. While there are some risks to the fetus, including the risk of prematurity and low birth weight, most risks can be managed quite well6,7,10,11,13. Risks from medication can be managed during breastfeeding, as well5, 10, 13, 14, 15, 17. Some autoimmune diseases—those relating to hormonal function—may interfere with milk supply, however 19, 20. This occurs when a mother’s disease interferes with normal levels of thyroid or insulin, for example. This should be managed by correcting the hormone to its normal levels, but many women are unaware of this possibility, especially with diabetes or pre-diabetes20.
One often-repeated concern regarding breastfeeding has been made which deserves special attention. Early studies of the hormone prolactin on nursing mice and in women with rheumatoid arthritis indicated that prolactin, and therefore breastfeeding, increased the severity and number of flares postpartum for women with rheumatoid arthritis who were having their first child18. This finding was often quoted by later researchers without much discussion6, 15. Frustratingly, not a single one of these studies controlled for partial breastfeeding versus exclusive breastfeeding, although they did divide breastfeeding mothers into those breastfeeding their first child versus those breastfeeding subsequent children. There was some acknowledgement that the sensitivity to prolactin may be genetic. In patients with multiple sclerosis, partial and exclusive breastfeeding mothers had different outcomes5, 8, 9.
Additionally, many women who chose to breastfeed in these earlier studies discontinued their medications in order to do so, making it difficult to distinguish between symptoms linked to breastfeeding and those due to the lack of medication. In studies of women with inflammatory bowel disease, breastfeeding was first believed to be associated with increased disease activity postpartum, but further analysis showed that when medication use was taken into account, the difference in disease activity was negligible15, 16. This underscores the importance of critically examining studies relating to disease activity and breastfeeding. Unfortunately, there are very few well-done studies to date relating to disease activity and breastfeeding specifically. Research in this area is starting to increase, but may not be available for several years. The reality is that the hormonal interplay of postpartum and breastfeeding with the immune system is so complex that we are just barely beginning to scratch the surface.
During my second pregnancy, my symptoms improved so much that I was able to stop taking daily medications. In fact, thanks to the hormonal influence of breastfeeding, I have not yet needed to start taking them again, even though my daughter is now 14 months old. Breastfeeding has actually proved to be pain-relieving for me. I often come home from school fatigued and in pain, to flop into my bed with my baby girl and nurse, only to find my energy increased and my pain gone. I tried finding an explanation for this phenomenon, but research in this area is scarce, at least as far as mothers are concerned. Joanna was able to control her symptoms throughout her pregnancy with the medication she was taking, but she suffered a very bad flare immediately postpartum, necessitating some creative thinking in order to breastfeed her child. She is now on a different medication.
What are a mom's major concerns when she is dealing with an immune disorder and an infant?
Dealing with symptoms and worries about the side effects of medication are probably the top two concerns of mothers with autoimmune disorders. Getting accurate, evidence-based information is a challenge because many doctors are not well-versed in current research in these areas. Despite the ameliorating effect breastfeeding has on my pain, I don’t always have time to breastfeed the pain away. As a busy mom, I still have to weigh my symptoms against taking medication occasionally. I know that at some point, the hormonal influence which keeps the majority of symptoms at bay will decline and I will need to decide whether to discontinue breastfeeding, find a breastfeeding compatible medication, or take my chances continuing to breastfeed with a poorly researched medication.
Joanna, on the other hand, had to deal with her symptoms much sooner. Immediately postpartum, she suffered such a severe flare-up that she had to get a doctor’s permission to nurse her one-day-old baby on the hospital toilet. Joanna decided that it would help her mental state to give an occasional bottle of formula as she dealt with her symptoms postpartum. However, by taking medication safe to use during pregnancy and beyond, she was able to continue breastfeeding her daughter for a year. Her doctors’ support was very important as they encouraged her desire to breastfeed. Her daughter is now a vibrant, healthy six year old.
Many mothers with inflammatory bowel disease are hesitant to try breastfeeding. Joanna has this to say: “Don’t be afraid to breastfeed. As long as you can find a medication that is compatible with breastfeeding, the medication will keep you healthy, and then your baby will get what he or she needs and be able to thrive. But don’t let yourself feel guilty if you are breastfeeding and need to supplement with an occasional bottle of formula. And if you need a stronger medication that is not compatible with breastfeeding, remember that it is better to have a healthy mother whose baby is on formula. You are doing the best that you can with the body you have been given.”
How can a Breastfeeding USA Counselor be of help?
Breastfeeding USA Counselors offer encouragement and share evidence-based information. They listen to and empathize with mothers’ concerns. They discuss problems that arise or might potentially arise and think of ways to mitigate them ahead of time. For example, if a mother has concerns that she might not always be available to breastfeed as needed, a Breastfeeding Counselor can provide information about pumping, both to increase and maintain the mother’s milk production, and to ensure that there is extra milk in the freezer so baby can be supplemented when necessary. If a mother is in pain, a Breastfeeding Counselor can help her find alternative nursing positions so that she can comfortably breastfeed. Breastfeeding Counselors reassure mothers that even if they do need to supplement with formula, as long as they are continuing to breastfeed, their babies will be getting important immunological and nutritional support. They can also help mothers to find ways to make sure that occasional supplementation does not begin to interfere with milk production.
"Breastfeeding USA Counselors”) are often the first line of support and are aware that some autoimmune diseases may lead to decreased milk production. They cannot diagnose an autoimmune condition or hormonal imbalance, but they are able, for example, to refer a mother to her doctor when she has unexplained low milk production to rule these out possible causes, even if she does not have a previous history of these disorders.
In addition, Breastfeeding USA Counselors help mothers find vital information about medications from sources such as Medications and Mothers’ Milk, the Infant Risk Hotline, and LactMed. This information can help mothers talk to their doctors about finding the right medications to both control their symptoms and safely continue breastfeeding. There is support available for mothers with autoimmune diseases.
1. American Autoimmune Related Disorders Association. (2013). Autoimmune Information: Questions and answers. Retrieved from https://www.aarda.org/q_and_a.php
2. Copstead, L. E. & Banaski, J. (2010). Pathophysiology (4th ed). St. Louis, MO: Elsevier.
3. Paddock, C. (2011). Is Type 2 diabetes an autoimmune disease? Retrieved from http://www.medicalnewstoday.com/articles/222766.php
4. Crohn’s and Colitis Foundation of America. (2013). What are Crohn’s and Colitis? Retrieved from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-ulcerative-colitis/
5. Houtchens, M. (2013). Multiple sclerosis and pregnancy. Clinical Obstetrics & Gynecology, 56(2), 342-349. doi:10.1097/GRF.0b013e31828f272b
6. Elliott, A., & Chakravarty, E. (2010). Management of rheumatic diseases during pregnancy. Postgraduate Medicine, 122(3), 213-221. doi:10.3810/pgm.2010.05.2160
7. Østensen, M., Brucato, A., Carp, H., et al. (2011). Pregnancy and reproduction in autoimmune rheumatic diseases. Rheumatology, 50(4), 657-664.
8. Langer-Gould A, Huang SM, Gupta R, et al. (2009). Exclusive Breastfeeding and the Risk of Postpartum Relapses in Women with Multiple Sclerosis. Archives of Neurology. 66(8):958-963. doi:10.1001/archneurol.2009.132.
9. Langer-Gould, A., Gupta, R., Huang, S. et al. (2010). Interferon-gamma-producing T cells, pregnancy, and postpartum relapses of multiple sclerosis. Archives of Neurology, 67(1), 51-57. doi:10.1001/archneurol.2009.304
10. Levy, D. (2007) Clinical Feature: Autoimmune diseases complicate pregnancy. http://www.clinicaladvisor.com/autoimmune-disorders-complicate-pregnancy...
11. Borisow, N., Döring, A., Pfueller, C., Paul, F., Dörr, J., & Hellwig, K. (2012). Expert recommendations to personalization of medical approaches in treatment of multiple sclerosis: an overview of family planning and pregnancy. The EPMA Journal, 3(1), 9. doi:10.1186/1878-5085-3-9
12. Newman, J. (2009). Breastfeeding and illness. Retrieved from http://www.breastfeedinginc.ca/content.php?pagename=doc-B-I
13. Keeling, S. O., & Oswald, A. E. (2009). Pregnancy and rheumatic disease: “by the book” or “by the doc”. Clinical Rheumatology, 28(1), 1-9. doi:10.1007/s10067-008-1031-9
14. Makol, A., Wright, K., & Amin, S. (2011). Rheumatoid Arthritis and Pregnancy: Safety Considerations in Pharmacological Management. Drugs, 71(15), 1973-1987.
15. Moffatt, D., Ilnyckyj, A., & Bernstein, C. (2009). A Population-Based Study of Breastfeeding in Inflammatory Bowel Disease: Initiation, Duration, and Effect on Disease in the Postpartum Period. American Journal Of Gastroenterology, 104(10), 2517-2523. doi:10.1038/ajg.2009.362
16. van der Woude, C., Kolacek, S., Dotan, I., Oresland, T., Vermeire, S., Munkholm, P., & ... Dignass, A. (2010). European evidenced-based consensus on reproduction in inflammatory bowel disease. Journal Of Crohn's & Colitis,4(5), 493-510. doi:10.1016/j.crohns.2010.07.004
17. Wallace, D., Gudsoorkar, V., Weisman, M., & Venuturupalli, S. (2012). New insights into mechanisms of therapeutic effects of antimalarial agents in SLE. Nature Reviews. Rheumatology, 8(9), 522-533. doi:10.1038/nrrheum.2012.106
18. Brennan, P., & Silman, A. (1994). Breast-feeding and the onset of rheumatoid arthritis. Arthritis And Rheumatism, 37(6), 808-813.
19. Marasco, L. (2006). The impact of thyroid dysfunction on lactation. Retrieved from http://www.lalecheleague.org/ba/feb06.html
20. Nordqvist, C. (2013). Insulin’s role in making breast milk. Retrieved from http://www.medicalnewstoday.com/articles/262981.php
Published February 2014.
Copyright 2014 Breastfeeding USA, Inc. All rights reserved.
You may be wondering, “What is breastfeeding going to mean for me?” It’s a valid question! While a partner is not required, a supportive partner can be a key element in helping the mother to breastfeed.
Mother and baby may be the stars of the breastfeeding show, but partners play a major supporting role.
Some partners are worried that they won’t bond as well with the baby because they can’t be directly involved in feeding. Some feel a little jealousy over the unique relationship shared by the mother and child (Jordan & Wall, 1990). They are afraid that the only time they’ll get to interact with the baby is during diaper changing. An informal poll on a breastfeeding support group’s Facebook page revealed more concerns partners had about breastfeeding:
• “Once the baby was born, he wasn’t very comfortable with NIP [nursing in public]…it’s the thought of another man seeing my breasts that bothers him.”
• “My husband didn’t like not knowing exactly how much milk the baby was getting.”
• “He didn’t like how unsexy breastfeeding first appeared to him, especially when I was still ‘deflating’ after the engorgement.”
• “He totally supports me breastfeeding, but I think in the sex department he really enjoyed my breasts, so there is some jealousy mixed in with the love and support he has for breastfeeding.”
• “I think for him it was the lack of knowledge, but sharing what I was learning helped him feel a part of it.”
• “My husband’s cousin doesn’t want his partner to breastfeed because he can’t help.”
The good news is that families develop many creative ways to meet these challenges. Partners can and do help with breastfeeding! In fact, research has shown time and again that partners are an important source of support for breastfeeding mothers (Raj & Plichta, 1998). Mothers are more likely to initiate breastfeeding and breastfeed longer if their partner supports it (Giugliani, Caiaffa, Vogelhut, Witter & Perman, 1994). This makes sense because partners are in the trenches with mothers – witness to the 2 a.m. cluster feeds, engorgement and other issues that can pop up in breastfeeding. Partners are there when breastfeeding counselors are not available.
Research is informative, but what does this support look like in real life? There are many ways a partner can bond with the baby, strengthen the relationship with mom and support both mom and baby (Rempel & Rempel, 2011).
Strengthen your relationship
• Give Mom a break. Right after the baby has finished nursing, offer to take the baby so that she can relax. Suggest that she take a nap, eat a hot meal, read a book, take a bath, or just relax. Chances are, she wants a break but hasn’t asked. Don’t let her clean the house! Tell her you’ll find her when baby is ready to feed again.
• Take charge of the household. Take on a few extra responsibilities around the house so Mom can focus on getting breastfeeding off to a great start without worrying about the laundry or dishes.
• Talk about sex. Intimacy doesn’t have to stop when breastfeeding starts. What’s important is to keep the lines of communication open, bearing in mind how she is physically ready at different stages of postpartum.
• Assist with night feeds. Breastfeeding does not mean a free pass for partners to sleep all night. If not co-sleeping, partners can bring baby to Mom for night feeds and then put baby back to sleep – allowing Mom to catch a few extra winks.
Bond with baby
• Go skin to skin. You probably already love touching your baby’s soft skin, so take it further and hold your diapered infant against your bare chest. At birth, skin to skin contact will help a newborn stabilize vital signs after the stress of birth. Skin to skin is beneficial at any age and can help babies and partners bond.
• Sing or talk to baby. Did you know that the lower pitch and deeper tones of a male voice can both calm and intrigue an infant? Bonus points if you do this during skin- to-skin time, when the infant can feel the vibrations of your voice through your chest!
• Perfect your baby dance. Most infants love to be rocked, lightly bounced, walked or gently swayed, which can have a calming effect on an infant. Experiment to find out what your baby likes, and pull it out during fussy times.
• Actively share the reins of child care. This is where we strongly encourage you to change the diapers. However, this is not the only way you can get hands on with your baby! Burping, bathing, dressing, calming and playing are all ways to interact and bond with a young baby.
Support the breastfeeding relationship
• Be the expert. Make it your second job to read up on evidence-based breastfeeding information. Know your state’s laws, so if she gets harassed for breastfeeding in public, you can jump in with the facts. Having more knowledge may make you feel more comfortable with breastfeeding, and you will be in a better position to help Mom with questions.
• Be the coach. Help Mom to feel comfortable with NIP. Practice with her at home so that she becomes comfortable arranging herself and the baby, getting latched, and breastfeeding with a minimum of fuss. Keep an eye out for comfortable locations to nurse when baby is ready. While Mom is nursing, act as if this is the most natural thing in the world, because it is!
• Be the personal assistant. Make sure Mom has what she needs during a nursing session – snacks, water, pillows, etc. Help her get comfortable or position the baby, if she needs it.
• Be the gatekeeper. A new baby is exciting, and everyone wants to be a part of the magic. It’s up to you to make sure Mom and baby don’t get overwhelmed, especially in the first few weeks.
• Be the cheerleader. Armed with your knowledge about normal newborn behaviors, you will be able to remind Mom that cluster feeding, for example, is normal and then praise her for meeting baby’s needs.. Thank her for breastfeeding to show her how you value her efforts. Let Mom vent whenever she needs to, and cheer about her progress toward her breastfeeding goal. If there are any ongoing problems, encourage her to seek help by reaching out to a breastfeeding counselor.
When it comes to breastfeeding, partners can make a big difference. Breastfeeding is a family affair - the whole dynamic is affected by how mother and baby are doing. Supporting your partner in her goal to breastfeed will strengthen that dynamic and benefit everyone in the family.
Giugliani, E. R. J., Caiaffa, W. T., Vogelhut, J., Witter, F. R., Perman, J. A. (1994). Effect of Breastfeeding Support from Different Sources on Mothers' Decisions to Breastfeed. Journal of Human Lactation, 10, 157-161.
Jordan P.L., Wall V.R. (1990). Breastfeeding and fathers: Illuminating the darker side. Birth, 17, 210-2
Raj, V.K., Plichta, S. B. (1998). The Role of Social Support in Breastfeeding Promotion: A Literature Review. Journal of Human Lactation, 14, 41-45.
Rempel, L. A., Rempel, J. K. (2011). The Breastfeeding Team: The Role of Involved Fathers in the Breastfeeding Family. Journal of Human Lactation, 27, 115-121.
© Breastfeeding USA, all rights are reserved.
What is antenatal (prenatal) milk expression? Why would women do it? Antenatal milk expression (AME) refers to extracting colostrum (the first milk) from the breast prior to birth, usually by hand expressing. In recent years, AME has been suggested to some mothers who have Type I or gestational diabetes. Babies born to mothers with diabetes may be at an increased risk of being hypoglycemic (low blood sugar) at birth and are sometimes supplemented with formula in an attempt to increase their glucose levels. However, formula supplementation, particularly early on, can have devastating effects on breastfeeding success. In addition, formula supplementation – even just one bottle – can carry health risks for the infant.(1)
For these reasons, some healthcare providers are now suggesting that mothers with Type I, or gestational diabetes, express their colostrum before their babies are born. This has triggered a hot debate raising many questions surrounding safety, efficacy, and whether there are nutritional differences between antenatally expressed colostrum and the colostrum that is produced post birth.
Harold Waller conducted some of the earliest studies of antenatal milk expression. He was mostly interested in understanding why long-term breastfeeding failed during a time when little was known about how lactation was maintained in humans. He used AME to determine if teaching mothers hand expression techniques prenatally improved breastfeeding rates.(2,3) Articles on AME from Waller’s time until post-2000 are scant, but those that exist focus on AME as a method to prepare women to breastfeed, and the expressed colostrum was discarded.(4) However, today AME is more focused on collecting the colostrum prenatally for supplementing infant feeding, particularly for babies who are at risk of hypoglycemia at the time of birth.(4)
There may be many reasons that antenatally expressed milk may be beneficial. They include reduction in the use of formula, increase in breastfeeding rates, and additional nutritional and immunologic protection. Formula supplementation occurs for a variety of reasons(5,6), but if pre-expressed colostrum was readily available, formula use may diminish. Mothers with Type I and gestational diabetes often have babies who are supplemented with formula due to unstable infant glucose levels at birth(7). However, in many cases these supplemental feeds may be unnecessary, as the tests used to determine infant glucose levels can be quite unreliable (8,9). Late onset of lactogenesis II (mature milk production) occurs frequently in mothers with Type I and gestational diabetes. This outcome may be hormonally influenced(7), but could also be caused by not breastfeeding or expressing frequently enough, which can be the result of formula supplementation.(10)
Diabetic mothers may not be the only group who could benefit from antenatal milk expression. Expectant mothers who are known to have insufficient breast tissue, polycystic ovarian disease, multiple sclerosis, or those who have undergone breast surgery, may all benefit from AME. (7) In addition, mothers who have medical concerns about early milk production may benefit from AME.
Breastfeeding success is important for the mother, given the fact that it is known to lower blood pressure, decrease the risk of premenopausal breast cancer, decrease the risk of ovarian cancer, provide protection against osteoporosis, and assist in losing weight gained from the pregnancy.(11,17) However, with the known risks of formula feeding and the importance of ingesting colostrum and mature breast milk, breastfeeding may be even more critical for an infant.(18,20) Colostrum is considered the “early milk,” can exhibit a wide range of thickness and color, and has the right mix of minerals, vitamins, proteins, and fats for newborns.(21) Ingesting this “early milk” has many effects on the newborn body. It acts as a laxative to assist the newborn in expelling meconium, the first dark tarry stools from the digestive tract. In addition, it is a living culture of cells that provide immunization and protection against bacteria and viruses that the newborn encounters.(18) During the third trimester of pregnancy, the breasts begin to produce colostrum. Some women leak this fluid and choose to collect and freeze it to feed to the newborn, if necessary. However, no studies so far have determined how prenatal and postnatal colostrum might differ in both nutritional and cellular content.
It must be noted that many of the studies that involve the use of antenatal milk expression have low sample sizes or inadequate experimental design.(22) Thus, the safety and efficacy of antenatal milk expression for the purposes of retaining colostrum or preparing for breastfeeding have not been thoroughly evaluated. For more discussion on this topic see(23).
Concerns with antenatal milk expression
Antenatal milk expression is usually suggested to start between gestational weeks 34 and 37 (7,24). Because nipple stimulation can lead to oxytocin release and oxytocin is known to play a role in cervical ripening and induction of labor, one concern is the possibility of inducing labor too early. One recent study has indicated that infants of mothers who have practiced AME have lower birth weights and shorter gestation time, which may mean that nipple stimulation during AME caused cervical ripening and labor induction prematurely (25). Those attempting to interpret these results should note that this study had low sample sizes and restricted participants to mothers with diabetes, which means that generalization of these results to non-diabetic mothers would be inappropriate. Another measure that can indicate whether AME may lead to increased risk of premature labor is number of infant admissions to special care units. Two recent studies have found that infants born to mothers who have antenatally expressed milk may have an increased risk of admission to special care units (26,27), although both studies were flawed to some degree. Soltani (2008) was not formally published in a peer-reviewed journal, and thus a complete analysis of experimental design is not possible. In addition, it should be noted that Soltani (2008) recognized that low sample size of the study made data interpretation difficult. Forster (2009) also had low sample sizes and questionable experimental design. For more discussion and an in-depth analysis of Forester (2009) methodology, see Chapmen (2012).
Ultimately, given the lack of reliable studies, it is difficult to determine if AME would actually lead to early initiation of labor that may result in low birth weight or increased risk of admission of the infant to a special care unit. Certainly, more studies about labor initiation should be undertaken. However, several questions come to mind such as: How much oxytocin is released during nipple stimulation? How does the level of oxytocin release during AME compare to other behaviors the pregnant human female exhibits such as kissing, orgasm, cuddling with other children or her partner? If nipple stimulation during AME causes oxytocin release that results in premature labor, are mothers who are currently nursing a toddler while in their third trimester at an increased risk of premature labor? Will oxytocin spikes from any of these behaviors (i.e. AME, orgasm, nursing a toddler) cause early onset of labor?
Unfortunately, few studies that attempt to answer such questions exist. Surprisingly, scientists still do not fully understand what causes the onset of labor. However, it is known that several physiologic, anatomical, and hormonal changes occur prior to the onset of labor, indicating that induction of labor is a complex process that involves not only oxytocin release, but also a host of other biologic events (28-30). In addition, oxytocin is known to elevate during sexual behavior in multiple different species (31), and in the human female can elevate significantly above baseline after stimulation through orgasm (32). One behavior, nipple stimulation, may occur through sexual contact or when a mother is pregnant and still nursing another child. However, oxytocin release from nipple stimulation is significantly less in the pregnant woman compared to the non-pregnant state (33). In at least one study, pregnant nursing mothers have not been found to be at an increased risk of preterm labor (34). Given this information, it seems that nipple stimulation, as the result of AME, is unlikely to cause early onset labor. At the same time, each woman is unique. If she chooses to engage in AME, she should be aware of the signs of preterm labor, especially if she experienced preterm labor in a previous pregnancy, and should discuss the safety of this practice and any other concerns with her care provider prior to initiation.
A mother who is considering antenatal expression needs to investigate this topic fully to determine if it right for her individual situation. A mother who chooses to antenatally express milk and plans to bring it to the hospital should talk to her care provider and hospital prior to birth as they may not have encountered this frequently before. A check with one hospital in a suburb of Chicago revealed that no protocols exist for antenatal milk expression or storage. A few hospital protocols from Australia and New Zealand are online (See Links 1 and 2). Antenatally expressed milk needs to be placed in collecting tubes and frozen(35,36), unless the mother is going to be induced or have a planned cesarean birth within a day or two. Then the colostrum can be safely kept at room temperature up to 24 hours(37,38) or kept in the refrigerator for up to 8 days.(39,40) Ideally, the colostrum would be used within 72 hours.(35,41,42) If the mother has frozen colostrum, she will need to have access to a freezer upon arrival at her birthing location. In addition, syringes, cups or spoons should be available for use to feed the baby the colostrum because of the small quantities and the potential for early bottle-feeding to interfere with breastfeeding. Talking to the hospital’s International Board Certified Lactation Consultant (IBCLC), if one is on staff, prior to giving birth may be beneficial to determine if the hospital is equipped with necessary supplies or if a mother will be required to bring her own (i.e collecting tubes, pumping supplies).
Expression of milk prior to birth may be beneficial for some, but is not required by all. Today, mothers who know they may need extra colostrum at birth may use this practice. Although more research is needed to better evaluate the safety, efficacy, and benefits of AME, existing published studies can give us insights into the possibility for this practice to positively influence breastfeeding rates and reduce formula supplementation.
1. Walker, M. (2004). Just One Bottle Won't Hurt - or Will It? Retrieved March 11, 2013
2. Waller, H. (1946). The early failure of breast feeding: A clinical study of its causes and their prevention. Archives of Disease in Childhood, 21(105), 1-12.
3. Waller, H. (1950). The early yield of human milk, and its relation to the security of lactation. Lancet, 53-56.
4. Chapman, T. (2012). Antenatal breast expression: A critical review of the literature. Midwifery, doi: 10.1016/j.midw.2011.12.013.
5. Gagnon, A. J., Leduc, G., Waghorn, K., Yang, H., & Platt, R. W. (2005). In-hospital formula supplementation of healthy breastfeeding newborns. Journal of Human Lactation, 21(4), 397-405.
6. Tender, J. A. F., Janakiram, J., Arce, E., Mason, R., Jordan, T., Marsh, J., . . . Moon, R. Y. (2009). Reasons for in-hospital formula supplementation of breastfed infants from low-income families. Journal of Human Lactation, 25(1), 11-17.
7. Cox, S. G. (2006). Expressing and storing colostrum antenatally for use in the newborn period. Breastfeeding Review, 14(3), 11-16.
8. Cornblath, M., Hawdon, J. M., Williams, A. F., Aynsley-Green, A., Ward-Platt, M. P., Schwartz, R., & Kalhan, S. C. (2000). Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics, 105(5), 1141-1145.
9. Hawdon, J. M. (2005). Blood glucose levels in infancy-clinical significance and accurate measurement. Infant, 2(2), 24-27.
10. Wight, N., & Marinelli, K. A. (2006). ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates. Breastfeeding Medicine, 1(3), 178-184.
11. Baker, J. L., Gamborg, M., Heitmann, B. L., Lissner, L., Sørensen, T. I. A., & Rasmussen, K. M. (2008). Breastfeeding Reduces Postpartum Weight Retention. American Journal of Clinical Nutrition, 88(6), 1543-1551.
12. Becher, H., Schmidt, S., & Chang-Claude, J. (2003). Reproductive factors and familial predisposition for breast cancer by age 50 years. A case-control-family study for assessing main effects and possible gene-environment interaction. International Journal of Epidemiology, 32(1), 38-48.
13. Carranza-Lira, S., & Mera Paz, J. (2002). Influence of number of pregnancies and total breast-feeding time on bone mineral desnity. International Journal of Fertility and Women's Medicine, 47(4), 169-171.
14. Paton, L. M., Alexander, J. L., Nowson, C. A., Margerison, C., Frame, M. G., Kaymakci, B., & Wark, J. D. (2003). Pregnancy and lactation have no long-term deleterious effect on measures of bone mineral in healthy women: a twin study. The American Journal of Clinical Nutrition, 77(3), 707-714.
15. Rosenblatt, K. A., & Thomas, D. B. (1993). Lactation and the risk of epithelial ovarian cancer. International Journal of Epidemiology, 22(2), 192-197.
16. Yen, M., Yen, B. L., Bai, C., & Lin, R. S. (2003). Risk factors for ovarian cancer in Taiwan: a case-control study in a low-incidence population. Gynecologic Oncology, 89(2), 318-324.
17. Zheng, T., Duan, L., Liu, Y., Zhang, B., Wang, Y., Chen, Y., . . . Owens, P. H. (2000). Lactation reduces breast cancer risk in Shandong Province, China. American Journal of Epidemiology, 152(12), 1129-1135.
18. Hanson, L. A. (2007). Session 1: Feeding and infant development breast-feeding and immune function. Proceedings of the Nutrition Society, 66(3), 384-396.
19. Luopajärvi, K., Savilahti, E., Virtanen, S. M., Ilonen, J., Knip, M., Åkerblom, H. K., & Vaarala, O. (2008). Enhanced levels of cow's milk antibodies in infancy in children who develop type 1 diabetes later in childhood. Pediatric Diabetes, 9(5), 434-441.
20. Tiittanen, M., Paronen, J., Savilahti, E., Virtanen, S. M., Ilonen, J., Knip, M., . . . Vaarala, O. (2006). Dietary insulin as an immunogen and tolerogen. Pediatric Allergy and Immunology, 17(7), 538-543.
21. Lauwers, J., & Swisher, A. (2011). Counseling the Nursing Mother A Lactation Consultant's Guide (5 ed.). Sudbury, MA: Jones & Bartlett Learning.
22. Chapman, T. (2012). Antenatal breast expression: Exploration and extent of teaching practices amongst International Board Certified Lactation Consultant midwives across Australia. Women Birth, doi:10.1016/j.wombi.2012.01.001. doi: 10.1016/j.wombi.2012.01.001
23. Cox, S. G. (2010). An ethical dilemma: should recommending antenatal expressing and storing of colostrum continue? Breastfeeding Review, 18(3), 5-7.
24. Service, W. S. H. (2012, June 2012). Antenatal Milk Expressing Retrieved January 31, 2013, from http://www.healthpoint.co.nz/download,322591.do
25. Soltani, H., & Scott, A. M. S. (2012). Antenatal breast expression in women with diabetes: outcomes from a retroscpective cohort study. International Breastfeeding Journal, 7(18), 1-5.
26. Forster, D., McEgan, K., Ford, R., Moorhead, A., Opie, G., Walker, S., & McNamara, C. (2009). Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial. Midwifery, 2, 209-214.
27. Soltani, H. (2008). Antenatal breast expression and the risk of labour induction: a study in a baby friendly hospital. Paper presented at the The International Confederation of Midwives Conference, Glasgow.
28. Garfield, R. E., Saade, G., Buhimschi, C., Buhimschi, I., Shi, L., Shi, S. Q., & Chwalisz, K. (1998). Control and assessment of the uterus and cervix during pregnancy and labour. Human Reproduction Update, 4(5), 673-695.
29. Gimpl, G., & Fahrenholz, F. (2001). The Oxytocin Receptor System: Structure. Function, and Regulation Physiological Reviews, 81(2), 629-683.
30. Castracane, V. D. (2000). Endocrinology of preterm labor. Clinical Obstetrics and Gynecology, 43(4), 717-726.
31. Carter, C. S. (1992). Oxytocin and sexual behavior. Neuroscience & Biobehavioral Reviews, 16(2), 131-144.
32. Carmichael, M. S., Warburton, V. L., Dixen, J., & Davidson, J. M. (1994). Relationships among cardiovascular, muscular, and oxytocin responses during human sexual activity. Archives of Sexual Behavior, 23(1), 59-79.
33. Amico, J. A., & Finley, B. E. (2008). Breast stimulation in cycling women, pregnant women and a woman with induced lactation: pattern of release of oxytocin, prolactin and luteinizing hormone. Clinical Endocrinology, 25(2), 97-106.
34. Moscone, S. R., & Moore, M. J. (1993). Breastfeeding during pregnancy. Journal of Human Lactation, 9(2), 83-88.
35. RamÍrez-Santana, C., Pérez-Cano, F. J., Audí, C., Castell, M., Moretones, M. G., López-Sabater, M. C., . . . Franch, A. (2012). Effects of cooling and freezing storage on the stability of bioactive factors in human colostrum. Journal of Dairy Science, 95(5), 2319-2325.
36. Takci, S., Gulmez, D., Yigit, S., Dogan, O., Dik, K., & Hascelik, G. (2012). Effects of freezing on the bactericidal activity of human milk. Journal of Pediatric Gastroenterology and Nutrition, 55(2), 146-149.
37. Nwankwo, M. U., Offor, E., Okolo, A. A., & Omene, J. A. (1988). Bacterial growth in expressed breast-milk. Annals of Tropical Pediatrics, 8(2), 92-95.
38. Pittard III, W. B., Anderson, D. M., Cerutti, E. R., & Boxerbaum, B. (1985). Bacteriostatic qualities of human milk. The Journal of Pediatrics, 107(2), 240-243.
39. Ogundele, M. O. (2002). Effects of storage on the physicochemical and antibacterial properties of human milk. British Journal of Biomedical Science, 59(4), 205-211.
40. Pardou, A., Serruys, E., Mascart-Lemone, F., Dramaix, M., & Vis, H. L. (2009). Human milk banking: influence of storage processes and of bacterial contamination on some milk constituents. Neonatology, 65(5), 302-309.
41. Igumbor, E. O., Mukura, R. D., Makandiramba, B., & Chihota, V. (2000). Storage of breast milk: effect of temperature and storage duration on microbial growth. The Central African Journal of Medicine, 46(9), 247-251.
42. Silvestre, D., Lopez, M. C., March, L., Plaza, A., & Martinez-Costa, C. (2006). Bactericidal activity of human milk: stability during storage. British Journal of Biomedical Science, 63(2), 59-62.
© Breastfeeding USA 2013. All rights are reserved.
You've done a truly amazing thing. You nurtured a baby in your body and you birthed that baby. And you are still nurturing this baby as a breastfeeding mother. You and your baby are a nursing team.
You have probably met and overcome some big challenges to have this baby. If you and your baby are settled in at home, you can take this time to get to know each other. Let your baby nurse whenever he asks to give him the practice he needs, and to get your milk production off to a good start. You’ll learn how to enjoy your new babe and get some rest, while you figure out what’s next and what’s best you for and your nursing newborn.
Nobody was born already knowing exactly how to be a mother. That’s something we all have to learn to do. You will learn that nursing your baby can become easy and comfortable and satisfying for both of you. And as you learn more about being a mother, you’ll begin to see how to accomplish some things you want to do for yourself. You can begin to make some plans for your new life with your new babe.
Going back to school can be a challenge, but you have already overcome some hard ones. You are probably a very determined person. You can be confident that your decision and your wish to continue nursing are backed up by the law. 44 states have laws that protect and support breastfeeding mothers, as does the new US government health care act.2
If you decide to go back to school, try to wait at least until your baby is three months old. Just about then, his world will be getting bigger and he will be smiling at you. He will be able to show that he knows you very well. His body systems will be maturing and he may sleep a little longer during the night. He will be awake for longer periods during the day and his new behavior will help you set up a schedule. You will be able to plan your day a little better than before.
What will you need to do to be able go back to school for six or seven hours a day?
You will need childcare, to start. Check to see if your school provides childcare -some do! If you are living with family members, maybe they can help. Take the time to have a good discussion...many discussions, about every little detail of your plans. It’s a good thing to talk and talk and talk some more. Your enthusiasm will surely bring others to support your ideas and your plans. Whenever you decide to go back to school, it will be a smart choice. All families have to work things out sometimes. As a nursing mother, you have a really special position. As you bond with your baby and keep her healthy and enjoy this time, your actions may help the rest of your family appreciate and support you in a new way. Your baby will know that only you are his mother, and your family will watch this and come to appreciate your relationship. It’s worth asking for the kind of help that you need.
You are now a mother. That is a very special thing to be. That means that other kinds of help and support and discussion are now available to you. You can find support in groups of nursing mothers in your area or online. You may find support at your local hospital, at the birth center where you had your baby, at WIC, or at a local Breastfeeding USA Chapter. There will be places where nursing mothers with the same problems and concerns can talk to a counselor or to each other and help each other. It really works. You’ll see that people do want to help you and your fine, sweet baby.
You will need to get a breast pump, so here is some information about choosing the right kind for your situation:
Using your hands helps your “let-down”...when the milk first begins to flow... before you start pumping, to help increase the amount of milk you pump. And using your hand to express your milk before you pump is more like what your baby does to get his milk, so it makes pumping more efficient. Using “hands-on” pumping...massaging and compressing your breast during pumping... also helps. You’ll get good at it in no time, you’ll see. Some mothers get so good at hand expression that they never use a pump at all. Counselors who know about nursing can show you or explain it to you.
You can learn more about pumping here.
Frequent draining of your breasts, especially once you start to be away from your babe, is important for your comfort and breast health. Remember that eating well will help you to get back into shape faster. No matter what else you do, don't forget to cuddle your baby and sleep when your baby sleeps. It makes sense for every nursing mother!
You can start practicing to pump and store your milk about a month before going back to school. There’s good information about storing your milk on the websites already mentioned. If you live near your school, you may be able to go home for lunch and nurse your baby. If your school has a nurse’s office, it might be a good private place to pump your milk during the day. You may be able to store it there, as well. You can bring a cooler if there is no refrigerator for your pumped milk while you’re at school and to transport it home.
As well as pumping during the day, you will want to nurse before you leave for school, as soon as you get home, and all through the rest of the day and night until you have to leave again. It will become a routine you can count on and feel comfortable with. You need to figure out a good schedule. You and your baby can do it.
Your WIC Peer Counselor may be able to give you some good information about going back to school and even help you learn hand expression. Maybe your pediatrician or family doctor will be able to help and support you, too. The Illinois Hospital Advocacy Initiative Breastfeeding Task Force has a “Breastfeeding Bill of Rights” that you may want to read. There is lots of support and help and goodwill out there for you.
Your life will continue to be challenging, as it has surely has been for a while. If you feel that you can, talk to an advisor in your grade and discuss your hopes and wishes for school going forward. You may want a lighter-than-normal schedule for the months of your first semester back at school. You may be able to have shorter hours. The most complicated part of being a nursing mother and going back to school is figuring out your schedule. Let your goal for the first few months be just to figure out how to actually do this. There is help out there. You deserve to have it. You can find it.
You may have to be flexible and let your sense of humor run free a little in the first month or so. You will need time to nurse your baby when you are at home with her. Plan to spend your first hour at home after school with your baby. You’ll need time at home to study so that schoolwork doesn’t become overwhelming. You’ll want time to play with your baby, to watch him change and grow every day. You’ll need some time to talk with friends. You will want to show off your baby. If you think about it, you may want to show your friends what breastfeeding is all about. They will be amazed. Probably no one has ever shown them anything like nursing a baby before.
Over time, things will get smoother. Your determination and commitment to yourself and your babe, and your desire to have a life that’s full and productive, will lead you in the right direction. You will get really good at several things at a time. When you have a specific question or problem, there are resources and people out there for you in your community and on the web. You’ve already shown yourself to be a person of great ability to do the hardest job anyone can do...to be a mom. As a nursing mom, you are giving your baby the best start in life, and by deciding to go back to school as a nursing mother, you are giving yourself a new best start as well. The two of you are truly an amazing pair.
- Benefits of Breastfeeding. Retrieved Apr il 2013: Natural Resources Defense Council http://www.nrdc.org/breastmilk/benefits.as
- 7 Ways Breastfeeding Benefits Mothers. Retrieved April 2013: Ask Dr. Sears
- Breastfeeding. Retrieved April 2013: The Office on Women's Health (OWH), part of the U.S. Department of Health and Human Services (HHS)
- United States Breastfeeding Committee (2010) Workplace Accommodations to Support and Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee;
- AAP Reaffirms Breastfeeding Guidelines (2012) Retrieved April 2013: American Academy of Pediatrics
- Supporting the Academic Success of Pregnant and Parenting Students (2013) U.S. Department of Education,Office for Civil Rights, Retrieved July 2013
© Copyright Breastfeeding USA, Inc. 2013 All rights are reserved. No part of this article may be reproduced, copied, modified or adapted, without the prior written consent of Breastfeeding USA and the author.