Breastfeeding Information

Maternal Autoimmune Disorders and Breastfeeding

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.

References

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.

Milk Sharing—Formal and Informal

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An Open Letter to Partners

Dear Partner,

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.

References

 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.

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

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.

Historical Perspective

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)

Potential Benefits

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.

Literature Cited

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.

For Teens: Going Back to School and Breastfeeding!

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:

You should also know how to hand express your milk. This video is also helpful.

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.

References:

  1. Benefits of Breastfeeding. Retrieved Apr il 2013:  Natural Resources Defense Council http://www.nrdc.org/breastmilk/benefits.as
  2. 7 Ways Breastfeeding Benefits Mothers. Retrieved April 2013:  Ask Dr. Sears 
  3.  Breastfeeding. Retrieved April 2013:  The Office on Women's Health (OWH), part of the U.S. Department of Health and Human Services (HHS)
  4.  United States Breastfeeding Committee (2010)  Workplace Accommodations to Support and Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; 
  5. AAP Reaffirms Breastfeeding Guidelines (2012) Retrieved April 2013: American Academy of Pediatrics
  6. 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.

Tell Me About Tongue Ties!

Have you noticed how so many babies these days are being diagnosed with tongue and/or lip ties? What are tongue ties, and do they really affect breastfeeding? Why do they seem to be more prevalent lately? How can they be treated?

There is a lot of confusion about tongue ties, also known as ankyloglossia. Here is some information to help you wade through the facts and myths surrounding this topic.

 What is a tongue tie?

The normal development of a fetus includes the growth of little bits of tissue called frenums (also known as frenulums), which attach the tongue to the floor of the lower jaw. We are all born with some of this tissue, but for some babies it is so tight that they cannot move their tongues properly. This can affect their ability to breastfeed, or even take a bottle or a pacifier. Tongue tie can also have other serious health effects. In a similar way, a baby's lips can be attached to his gums, making it difficult to get a good grasp on a nipple. Babies who have lip ties almost always also have tongue ties.

Tongues and lips are only considered *tied* if their movement is restricted, impairing mobility. It is important to note that many people have frenums which do not cause any problems at all. Each case needs to be assessed on an individual basis.

There are different kinds of tongue tie. They are classified according to where the frenum is attached on the base of the tongue.

Class 1 ties are attached on the very tip of the tongue. These are the ones that most people think of when they talk about tongue ties.

Class 2 ties are a little further behind the tip of the tongue.

Class 3 ties are closer to the base of the tongue.

Classes 1, 2, and 3 are also known as anterior ties.

Class 4 ties, also known as posterior ties (PTT), may be submucosal, ie. underneath the mucous membrane covering, so  they must be felt to be diagnosed. Babies with this kind of tie are often misdiagnosed as having a short tongue. This video shows how to recognise a PTT.

Lip ties are classified in a similar way.

They range from Class 1 which are tiny, reaching only from the underside of the upper lip to the top of the gum, to Class 4, which have tissue connecting the lip to right under the gum ridge, located between the positions where the top front teeth will emerge.

Tongue and lip ties are considered to be midline defects. Midline facial defects tend to run in families. These include cleft lip, submucosal cleft palate, cleft chin, extra or missing teeth, nasal atresia and deviated septum.

How and why does it affect breastfeeding?

Babies who are tongue-tied may have problems affecting a secure latch to the breast. They can overcompensate by increased suction causing nipple damage and pain. When they can no longer maintain latch through suction, there may be a click and a slight loss of suction or the baby may completely detach from the breast. This may not only cause pain, but also affect the baby’s ability to adequately drain the breast, leading to supply issues. In severe cases, baby is really not able to attach at all.

Why do we seem to be seeing more tongue ties now? 

Babies have always been born with tongue ties. You may have heard stories of midwives who used to keep one fingernail long and sharp to cut class 1 and 2 ties at birth as a matter of routine. When bottle feeding started to become popular, it was considered to be not just a viable alternative to breastfeeding, but actually superior to it, and mothers were encouraged to feed their babies “scientifically.” Tongue tie was one of the reasons given to wean the baby to a bottle, and most of the accumulated knowledge about it was forgotten. When breastfeeding became popular again, the attention to the problem re-emerged.

For a long time, only anterior tongue ties were recognized. It was easy to spot the typical heart-shaped tongue of ties which started at the tip of the tongue. Even so, it was very difficult to find a doctor who was willing to snip the tie, so mothers either suffered the pain or, more frequently, switched to bottle feeding.

But lately, in the past ten years, things have started to change. There has been a tremendous amount of new information from research studies, especially about posterior ties, and the use of lasers for very delicate surgery has revolutionized the treatment. The newest research is looking into environmental factors, and the possibility of a specific gene mutation being linked to the cause of tongue ties.

In a recent informal poll on a Facebook page for healthcare professionals dealing with tongue and lip ties, every one of the International Board Certified Lactation Consultants (IBCLCs) in private practice who responded stated that the vast majority (over 90%) of the babies they saw had tongue and/or lip ties.

Another Facebook page, which acts as an online support group for parents whose babies are tongue tied, has over 3,600 participants, with about 100 new people joining every week.

 What is going on?

First, you have to realize that IBCLCs in private practice tend to see the most difficult cases. Since it can hurt to nurse if your baby is tongue tied, many mothers stop breastfeeding in the first few days. Some of those who do seek help are told that breastfeeding is not affected by tongue ties, or that bottle feeding is the solution, or even that there is no such thing as a tongue tie. Those who persevere may eventually get their babies treated, but the tongue may not be released sufficiently, and so the problem persists. Many of these mothers may have seen several health care providers before finding that knowledgeable and supportive Facebook page. In one case, a mother saw ten IBCLCs before she found one who recognized the problem! All these mothers are looking for validation and for personal recommendations to practitioners who both recognize and release ties.

There are many myths about lip and tongue ties, but here are some facts.

  •  It is possible to  have both an anterior (frontal) tie AND and posterior one. Although some (anterior) ties are associated with heart-shaped tongues, tongue tips can look rounded or squared if there is posterior tie
  •  Posterior ties are often misdiagnosed as a short tongue.
  •  A baby with a tongue tie may be able to stick out his tongue.
  •  Tongue and lip ties, like the webs of skin between your thumbs and index fingers, do not  suddenly shrink, stretch, or disappear.
  •  Tongue and lip ties can affect a baby's ability to breastfeed.
  •  Babies who are tongue tied are often not able to drink well from a bottle or take a pacifier.
  •  Older tongue-tied babies may have difficulty in swallowing solid food. Their tongues may not be mobile enough to move the food to the back of their  mouths.
  •  A mother whose baby is tongue tied may start out with plenty of milk, but the lack of adequate stimulation to her breasts can result in a decrease of her  milk production. This, of course, can lead to poor weight gain in the baby.
  •  Digestion starts in the mouth, and so tongue ties can lead to digestive problems like colic and reflux.
  •  Tongue tie can affect speech, causing both delays in speech onset, and also in the ability to form certain sounds and words correctly.
  • Tongue tie can affect the way teeth come in. For example, the front bottom teeth may be pulled inwards. Babies with tongue ties often have narrow  palates, so teeth may be overcrowded.
  • When you see a lip tie, there will almost always also be a tongue tie.
  • Babies who have lip ties are not able to open up and properly flange their lips, and this can affect their ability to grasp the breast.
  • Lip ties may push the two front teeth apart, leading to expensive orthodontic work later. In many cases, if the lip tie is not released, the front teeth will  grow apart again after the braces have been removed.
  • Tooth decay can be caused by food being pushed into the pockets on either side of a lip tie.
  • It may seem trivial, but tongue-tied babies will eventually become tongue-tied children and adults who cannot lick an ice cream cone or French kiss - not  trivial to those affected; it is much easier, safer, and less traumatic to fix a tongue tie in infancy than to wait until later childhood or adulthood.

Treating tongue and lip ties

If you suspect that your baby has a lip or tongue tie, you will want to get it evaluated. This is where an experienced IBCLC can help. The number of health care providers who are knowledgeable about tongue ties is growing, and your local IBCLC will be able to recommend a practitioner (usually a pediatric dentist or Ear, Nose and Throat Specialist (ENT) who can diagnose and release the tie.

Tongue and lip ties can be released either with a scalpel or scissors, or by laser. Lasers do not require anesthesia, and *seal* the revision instantaneously, so there is minimal bleeding and no risk of infection.

Here are three videos of older children's tongue ties being released by lasers. Most people are amazed at how quickly it can be done. Warning, these are graphic! 

Laser Anterior Tongue Tie Revision In Calgary, Alberta
Laser Posterior Tongue Tie Revision in Calgary, Alberta 
Lip tie release 
This video shows how the healing takes place, day by day:

After-care – who does what?

You will be able to nurse your baby immediately after the procedure, and many mothers notice a difference in the way their babies nurse right away. However, there is still more work to be done.

After a couple of hours your baby's mouth will start to be sore, and doctors usually recommend an over the counter analgesic. Some mothers prefer to use homeopathic preparations. Your baby may be fussy, but he or she will soon calm down. Do not be surprised if your baby refuses to nurse during this time because of the soreness. This is a very temporary nursing strike and usually resolves quickly. During this time, you can hand express or pump your milk to relieve engorgement, and feed it to your baby with a spoon, cup or bottle.

As the videos show, an incision is made into the frenum to release the tightness. This incision needs to be kept open while it heals. This is done very quickly, three or four times a day for about 2 weeks, by stretching the tongue and massaging the incision. This video shows how:

It is easiest to do the stretching from behind the baby's head. One way is to place him on the floor and sit behind him. With an older baby or a toddler, some mothers find it helps to positioning your knees over their child's shoulders to keep their arms from waving around.

A tongue-tied baby who cannot breastfeed properly learns to compensate. After his tongue has been released, he needs to learn how to nurse using a different set of muscles. This is where bodywork, like chiropractic and craniosacral therapy, can help by releasing the muscles needed. This bodywork is very gentle, done mostly with fingertips, and some of it can be done while the mother is holding the baby.

When the baby's latch to the breast is good, it should feel comfortable for the mother and enable the baby to breastfeed efficiently. An IBCLC who specializes in latch issues can help your baby get the deepest possible latch. The IBCLC can also teach you some gentle exercises to help your baby strengthen and stretch his newly-released tongue. If your baby has not previously been able to nurse, she can help you in getting him to the breast and in increasing your milk production.

 You can read more about aftercare here:

For more information about tongue and lip ties, see the references below.

 REFERENCES

1. Coryllos, E.  Watson Genna, C.  Salloum, A. (2004) Congenital tongue-tie and its impact on breastfeeding  American Academy of Pediatrics Section on Breastfeeding Newsletter, Summer 2004, 1-6 

2. Photos - "Is My Baby Tongue-tied?"  Retrieved April 2013

3. "Hazelbaker Assessment Tool for Lingual Frenulum Function" Retrieved April 2013 

4. “Swallow study for baby with posterior tongue tie.”Retrieved April 2013 

5. Forlenza, G. et al (2010), Ankyloglossia,  Exclusive Breastfeeding, and Failure to Thrive, Pediatrics Vol. 125 No. 6, 1500 -1504. Retrieved April 2013

6. Øyen, N, et al (2009), Familial Recurrence of Midline Birth Defects—A Nationwide Danish Cohort Study,  Am. J. Epidemiol.  doi: 10.1093/aje/kwp087  First published online: May 4, 2009.  Retrieved April 2013 

7. Kotlow, Larry, DDS Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie1 and Ankyloglossia (Tongue-tie) Retrieved April 2013

 8. Palmer, Brian, DDS, Frenum PresentationRetrieved April 2013

9. Hong, P et al, Defining ankyloglossia: a case series of anterior and posterior tongue ties. Int J Pediatr Otorhinolaryngol 2010; 74(9):1003-1006

10.  Notestine, Dr. Gregory, The Importance of the Identification of Ankyloglossia as a Cause of Breastfeeding Problems, Journal of Human Lactation 1990;  6(3):113-115

11. "The Sweet Release" Retrieved April 2013  Blacktating.Blogspot.com

© Breastfeeding USA. All rights are reserved. May 2013

Phone Apps for Breastfeeding Mothers

Being a modern breastfeeding mother definitely has its perks! Whether you're camped out on the couch nursing that newborn or expressing milk away from home, your smart phone or tablet offers a lot of beneficial help. Please keep in mind that this list of breastfeeding-friendly applications doesn't include any feeding trackers. Timing feedings (especially for first-time moms) may discourage breastfeeding on demand and paying attention to baby's cues. In addition, there aren't any formula-sponsored or breast pump-sponsored apps.

These apps are not a substitute for real-life support. Working with a Breastfeeding USA Counselor or IBCLC should always be the first step to troubleshooting breastfeeding issues.

  • Breastfeeding Solutions:
    Price: $4.99
    Description: Breastfeeding Solutions from author Nancy Mohrbacher, IBCLC, FILCA helps mothers troubleshoot breastfeeding problems and offers answers to common nursing questions.
    Pros: Easy-to-use interface; user-friendly navigation. Evidence based information, with cited articles. Common breastfeeding obstacles and myths addressed with workable solutions.
    Cons: Should not be used as a substitute for in-person support.
  • LactMed:
    Price: Free
    Description: LactMed is a searchable database of drugs and supplements that may affect breastfeeding.
    Pros: Easy to search. Lots of information. Shares references.
    Cons: Doesn't have Hale's risk categories (L1-L5)
  • Milk Maid
    Price: $2.99
    Description: Milk Maid allows mothers who express breastmilk to manage their stash.
    Pros: Records and times expressing sessions. Keeps track of inventory. Sets expiration dates. Allows you to differentiate between fresh milk and frozen milk. Exports data.
    Cons: Doesn't take feedings at the breast into account.
  • Growth (Charts)
    Price: Free
    Description: Growth (Charts) tracks your child's weight/height gain against the WHO's percentile curves.
    Pros: Uses WHO standards. Charts adjust for 0-19 years of age.
    Cons: Must upgrade to track more than one child.
  • Breastfeeding Management 2
    Price: $1.99
    Description: Breastfeeding Management 2 provides several calculators to help identify and manage early breastfeeding problems.
    Pros: Has 5 calculators, including weight loss. Identifies red flags.
    Cons: Shouldn't be used as a replacement for real-life support!!
  • Fooducate
    Price: Free
    Description: Fooducate scans a bar code and then gives the food a grade and shows pertinent information about its nutritional content. Helps nursing moms stay healthy and eat well for themselves and their little one.
    Pros: Over 200,000 products in its database. Gives healthier alternatives to less-healthy products. Grocery list capability.
    Cons: Not much info on fast food or other restaurants.
  • The Portable Pediatrician
    Price: $9.99
    Description: The Portable Pediatrician is a Dr. Sears' book-to-go, listing common ailments A-Z.
    Pros: Very detailed. Includes growth charts.
    Cons: Price
  • Ambiance
    Price: $2.99
    Description: Ambiance has over 2,500 soothing sounds to help nursing moms and fussy babies relax.
    Pros: Customizable. Collection keeps growing.
    Cons: None really. Pretty much does what it's supposed to.
  • Diaper Log
    Price: Free
    Description: Diaper Log tracks diaper output.
    Pros: Very simple. Lightweight. Doesn't track anything other than diapers.
    Cons: Can't edit info once it's entered.

Revised November 2013

© Breastfeeding USA. All rights are reserved.

How Much Milk Should You Expect to Pump?

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

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

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

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

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

Read on for the details about each of these factors.

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

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

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

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

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

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

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

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

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

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

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

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

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

Hands-on Pumping
Hands-on pumping is one evidence-based strategy to increase milk yield while pumping. Click here for the Breastfeeding USA website article describing this effective technique.

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

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

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

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

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

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

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

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

Used with Permission. Article also appears on the website Breastfeeding Reporter (http://www.nancymohrbacher.com/), where you can find complete article licensing information.

Diaper Output and Milk Intake in the Early Weeks

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

During the first day or two of life, breastfed babies receiving colostrum typically have one to two wet diapers and stools per day. After that, some health organizations suggest breastfeeding parents track daily diaper output to estimate milk intake. According to the International Lactation Consultant Association1 signs of effective breastfeeding are at least three stools per day after Day 1 and at least six wet diapers per day by Day 4. The Academy of Breastfeeding Medicine 2 considers indicators of adequate mother’s milk intake to be the transition from the first dark stools passed by the baby to yellow stools by Day 5 and three to four stools per day by the fourth day of life.

Two U.S. studies examined whether diaper output accurately reflects adequate milk intake. Both found that there was much room for error. One study 3 of 73 exclusively breastfeeding mother-baby couples monitored the babies’ weight loss and gain, breastfeeding patterns, and diaper output for the first 14 days. The researchers found that more stools during the first 5 days were associated with positive infant outcomes. More stools during the first 14 days were associated with the lowest weight loss and early transition to yellow stools. (Mean number of stools per day was four, but some babies had as many as eight.) The first day of yellow stools was a significant predictor of percentage of weight loss (the earlier the babies’ stools turned yellow, the less weight was lost). The average number of daily stools was not an accurate predictor of initial weight loss, but the more stools passed during the entire 14-day study period, the earlier birth weight was regained.

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

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

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

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

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

References
1International Lactation Consultant Association. (2005). Clinical Guidelines for the Establishment of Exclusive Breastfeeding. Raleigh, NC: International Lactation Consultant Association.

2Academy of Breastfeeding Medicine. (2007). ABM Clinical Protocol #2 (2007 revision): guidelines for hospital discharge of the breastfeeding term newborn and mother: "the going home protocol Breastfeeding Medicine, 2(3), 158-165.

3Shrago, L. C., Reifsnider, E., & Insel, K. (2006). The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates. Pediatric Nursing, 32(3), 195-201.

4Nommsen-Rivers, L. A., Heinig, M. J., Cohen, R. J., & Dewey, K. G. (2008). Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. Journal of Human Lactation, 24(1), 27-33.

5American Academy of Pediatrics. (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-841.

Copyright Nancy Mohrbacher. Used with Authors Permission.

Milk Sharing: Formal and Informal

For most of human history, the sharing of human milk has taken place in the form of one mother breastfeeding the baby of another. In most instances, the immediate benefit of this kind of milk sharing—the continued life of the baby—far outweighed any possible risks. Even today, during times of emergency or in remote areas, sharing human milk may be the only way to save the life of a child whose mother has been injured, killed or is gravely ill. There may be limited or no access to any other feeding alternatives. The World Health Organization lists “wet-nursing” and milk banks as being equal alternatives when mother’s own milk is not available.*

In the United States, mothers investigate multiple sources of human milk for their babies when they themselves are unable to provide their own milk. Some are able to obtain milk from established Human Milk Banking Association of North America (HMBANA) milk banks that have a standardized system of collecting milk and screening donors. Others turn to family members and close friends in a more informal milk sharing arrangement which may include breastfeeding the baby and/or sharing milk for breastmilk feeding. In this age of the internet, still others are using social networking tools to link up with mothers who may be willing to donate milk. There is much debate now on the advisability of informal milk sharing amongst friends or strangers.

Some in the lactation community are worried that informal milk-sharing will negatively impact the ability of HMBANA milk banks to find donors. While this has not been documented as yet, it is something to consider, and mothers may want to investigate the possibility of donating to one of these milk banks before entering a more informal arrangement. Much of the milk from these banks goes to ill or premature babies and thus their screening process for donors is fairly stringent. Mothers seeking milk for full-term, healthy babies may be unable to obtain milk from HMBANA banks or to afford the cost. Even for fragile babies, HMBANA milk may not be available due to lack of donors. It is a difficult situation. It would be wonderful if HMBANA banks were operating in every community and their milk was more available and affordable - a worthy project for any lactation group or hospital to undertake. It is unfortunate that access to formula is so much easier than finding a source for human milk.

The risks of formula feeding have been well-documented. Depending on the situation, they can range from immediate risk of mortality from infections or SIDS to more long-range risks of increased rates of obesity, diabetes and some kinds of cancer. Some risks are more likely to pose immediate harm than others; some risks have a higher statistical probability than others. But the risk exists, there is no doubt about that.

While the use of human-milk substitutes involves documented risks to the baby, milk sharing is not without risk, either. Human milk that is carelessly collected or stored may be contaminated by any number of potentially harmful microorganisms. Donor mothers may have diseases that could be transmitted through the milk; some may not even know that they are infected. Donor mothers may be taking drugs or herbs that could cause harm to the baby. It does seem that most donor mothers want to take all reasonable precautions to make sure that their milk poses no risk to the babies who receive it. Yet there is always the element of the unknown, even when using milk donated by friends or family.

As with any other health-related decision, mothers who choose to share milk informally need to weigh the risk versus the benefit to their babies. They need to take whatever measures they deem necessary to ensure the safety of the milk they are obtaining for their babies. Those measures could include having the donor fill out a questionnaire and/or submit to blood testing. Testing does not ensure that the milk will be “safe” for the baby. However, nobody can insure the safety of formula feeds, either, or the degree of risk if baby receives a human-milk substitute. There has been no research at this time comparing the risks of banked human milk versus informally shared human milk for babies in this country. There is no official place for mothers to report negative experiences they have had while engaging in informal milk sharing. It is a complex issue and one that deserves careful examination by anyone considering any kind of milk sharing.

Websites that advocate for informal milk-sharing, such as Eats on Feets, Milk Share, and Human Milk 4 Human Babies, contain lots of information on this topic. La Leche League International cautions against informal milk-sharing in its policy statement.

Again, mothers unable to nourish their babies with their own milk must decide for themselves, on a case by case basis, what is best for their situation. Parents are responsible for their own children and must live with the outcomes of their decisions. Mothers are encouraged to fully research the available options in order to make an informed decision.

For more information, see:
Use of Donor Human Milk from the FDA
Milk sharing: from private practice to public pursuitby James E Akre, Karleen D Gribble, and Maureen Minchin. International Breastfeeding Journal 2011, 6:8 (25 June 2011)
Biomedical ethics and peer-to-peer milk sharing by Karleen D. Gribble. Clinical Lactation, 3(3):109-112 (2012).

*From WHO: Global Strategy for Infant and Young Child Feeding, #18 (page 17):
“…..For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or human-milk bank, or a breast-milk substitute ……depends on individual circumstances.”

© Copyright Breastfeeding USA 2012. All rights are reserved.

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