Breastfeeding Information

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.

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

No one can know what life is like with a newborn baby before having one. Many say, “No one ever tells you what it’s really like.” That’s very true, because it’s a story that can’t be told beforehand. It will be a story that you and your baby will tell together.
But some things we can tell you for certain. These things have been studied and understood for quite a while. One of the things we know is the normal way newborns eat and the natural food they are meant to have.

You already know without anyone telling you that one of the main jobs in your life with your baby is feeding her. Feeding this baby from your breast is the easiest, healthiest, cheapest, safest, least tiring, most fascinating and delightful way to give your baby food. Feeding your baby can be simple and satisfying and healthy and amazing for the both of you if you nurse your baby.

Your body already started preparing food for your baby by making colostrum, an early kind of milk, when you were about 16 weeks pregnant. Now that your baby is here, you will have the right amount of that milk available from the moment she finds your breast. And she can find your breast all by herself when you lie back, and she lies flat on your body, sort of tummy-to-tummy. She can do that when she’s less than an hour old. You will watch her cute efforts to wiggle around and come to your breast without much help at all. She knows where to go and what to do when she gets there! She knows more than you do about this, so let her show you.

Only you are the mother of this baby, and others should honor what you decide for him. If you know what the best scientific evidence says about nursing your baby, you can act in the healthiest and happiest way for both of you, and everyone in the hospital should listen to you and support your wishes. There may be times when the hospital wants to do things to you and your baby because of hospital routines that may not be in the best interests of you and your newborn. One example of that is taking your baby away from you and giving him a bath before he’s even 6 hours old. He may not be ready to keep his temperature steady yet, especially after a bath.1,2 You can request that they wait a few more hours before the bath, and do it when you are close by, so that he can go right back on your skin to keep his temperature nice and stable. An even temperature is very important for his health.

When you first meet this new baby, he is ready to adjust well to life outside your body. It’s going to be your delight to watch him while he is resting on you and getting ready to nurse for the first time. No one should rush him or rush you. Let him do it in his own time. Remember you are the mother, and you can tell the hospital staff to let this baby stay on your body for at least an hour. He must adjust and then nurse for the first time before they do anything at all to him. That means no eye ointment or he won’t be able to see you well; no weighing, no shots. Nothing at all should disturb you and your baby in the first hour or so. You can tell your caregiver that your baby should have no bottles, no pacifier, just you. You can insist and the staff should honor your wishes. You are now a mother and this is your baby.

Here’s what all baby doctors and scientists want you to know about how to begin feeding your baby with your milk. Keep your baby with you and as close as possible day and night. That means right next to you in your hospital room. And that also means keeping your baby on your chest, with his bare skin on your bare skin for good long periods of time. All of a baby’s body functions, temperature and heart rhythm and blood pressure and breathing are nicely regulated by being on your body. When your baby stays close, you will very quickly get very good at seeing your baby’s “feeding cues.” That means you’ll see your baby do the little movements of his hands and mouth and body that mean that he is ready to nurse. That’s his way of asking for food. That’s his language.

While your baby is on your chest, he may bob his head around and find your nipple and begin to nurse while he is still half asleep. It’s amazing to see. He’ll just be doing what comes naturally. Babies love to nurse and they are born to suck, so in the beginning of your life with him, he may want to nurse a lot. He knows what he needs, so just follow his “cues”, and feed him whenever he asks. Babies who spend lots of time on their mom’s bare skin in the first days and weeks after birth cry less, eat and digest better. They also sleep well, and that’s great for you. Newborns really are meant to spend their early days and weeks as close to you as they can get. Just keeping your baby close to you makes him healthier. As time goes by you will see that it’s really the easiest way to keep him fed and happy and to keep your breasts comfortable. Plus think of all the wonderful cuddling you and your babe get to do.

The more you know about all the good things that will happen to both of you when you decide to nurse your baby, the more you’ll understand how really important it is. You’ll see that your decision to breastfeed will mean a lot more than just the easiest way to feed, or good health or saving money. It will mean that you are able to enjoy the deep and special and lasting attachment that happens to you and your babe when you are a breastfeeding pair. Your baby needs and wants the special food only you can give him... your milk... and you’ll be amazed at how much he really does want it.

While you are in the hospital, you will be able to have a nurse or a lactation expert— someone who knows about nursing—show you how to find a comfortable position for nursing. The expert will explain what your baby needs and what you need for a good beginning. You’ll learn how your baby changes over the first weeks of his life with you, and how your milk changes along with him. In just the first few days of your life together, you will become an expert on the subject of your new baby. You’ll learn about her ways. You’ll be surprised at how easy and pleasant and just plain amazing it is to nurse your baby and how well you both will do it together.

1World Health Organization. (2009). Newborn Care Until the First Week of Life: Clinical Practice Pocket Guide. Geneva, Switzerland: World Health Organization, 19.

2World Health Organization. (1997). Thermal Protection of the Newborn: A Practical Guide. Geneva, Switzerland: World Health Organization, 14.

© Copyright Breastfeeding USA 2012. All rights are reserved.

Choosing a Breast Pump

Claire was excited. “My baby is due next month,” she said, “and I still have not decided which breast pump to buy. Does it really matter which one I choose?”

You may have noticed how almost all “must have” list for pregnant parents includes a breast pump. Here are some things to consider.

Who needs a pump?
You may need a pump if:

  • your baby is not able to directly breastfeed
  • you will be separated from your baby because of his prematurity, or your work or schooling
  • under certain circumstances, if you need to increase your milk production

If you are staying home to care for your healthy newborn, you may not need a pump at all. For the occasion when you may want to go out without your baby, hand expression is an effective and cost-saving option.

A word about hand expression.
Hand expression is a very useful skill and is easy to learn. Ask your Breastfeeding USA Counselor to show you how to do it. You can see a simple animation of hand expression here:
http://ammehjelpen.no/handmelking?id=907 (Scroll down for English text.)

When is the best time to buy a pump?
This will depend on your own circumstances, because there are different kinds of pumps for different situations.

If either you or your baby is unable to nurse after birth, you should use a special hospital-grade pump. Your hospital will have one available for you to use during your stay, and they will let you know where to rent one if your baby is still unable to nurse when you go home.

If you are sure that you will be returning to work, you might want to consider buying a personal pump before the baby is born. That way you will have it available if you need to pump to comfort in the early weeks. However, these personal pumps should not be confused with the previously-mentioned hospital grade pumps, which are designed to help you establish milk production.

Not all pumps are created equal!
Don’t waste your money on a cheap pump. They do not work very well, are noisy, break down often, and can even cause nipple damage.

Check the length of the pump's warranty, because that is the expected lifetime of the pump!
As a general rule, it is a good idea to avoid pumps made by companies whose main business is selling bottles, nipples and other supplies needed by mothers who are formula feeding. In the long run, it is much cheaper to rent or to buy a good pump than to buy formula.

When buying a pump, consider whether that brand offers different fit options. 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. Pump nipple tunnels come in different sizes. Fit is an important aspect of pump comfort and efficiency.

If you need to rent or buy a pump, first check to see if you qualify for a free one from your local WIC agency.

There are so many breast pumps available today that it can be hard to decide which one is right for you. Here are some things to consider.

There are three kinds of pumps:

  • For occasional use.
  • For regular use.
  • For mothers who have not yet established a milk supply and/or whose baby is less than 8 weeks old.

Pumps for occasional use.
NOTE: These are all single user pumps that, like toothbrushes, should not be loaned or re-sold.

  • Manual pumps are designed for very occasional use - once or twice a week. They carry a 30-to-90 day warranty.
  • Small, motorized pumps are often chosen by mothers who are separated from their babies for about one or two feedings, once or twice a week. These pumps, which also have very short warranties, can be useful for emergencies. They are expensive to run on batteries, because the batteries need to be changed so frequently. Whenever possible, plug them into an electrical socket. They have a 90-day (3 months) warranty, and tend to be a bit noisy.

Pumps for regular use
Are you a mother who has already established a good milk supply and has a baby who is nursing well? If you will be separated from your baby because of work or school, you will need a dependable and efficient electric double pump. Some mothers find that pumping both breasts at once saves time and actually brings in more milk. See the Breastfeeding USA article To Pump More Milk, Use Hands-On Pumping for more ideas for bringing in more milk.

There are new multi-user electrical pumps in the $300 price range, which carry a three-year warranty. After you are finished with it, the pump can be loaned or sold to another mother who has her own personal accessory set, and even be recycled.

Some mothers prefer to rent the hospital-grade electric double pumps for the reasons below. Contact a Breastfeeding USA Counselor for the most current information on available breast pumps.

Pumps for mothers who have not yet established a milk supply and/or whose baby is less than 8 weeks old.
If this is your situation, you will probably need to rent a hospital-grade electric double pump:

Mothers of babies who:

  • are premature
  • are too sick to nurse
  • have physical anomalies (like a cleft palate) which may prevent breastfeeding
  • are having difficulties nursing for other reasons

Mothers who:

  • are exclusively pumping
  • have had breast reduction surgery
  • have medical conditions (like untreated low thyroid levels) which may make it difficult to produce a full milk supply
  • are relactating or inducing lactation for an adopted baby
  • are having difficulties nursing for other reasons

Hospital-grade electric pumps are specially designed to bring in and maintain a mother’s milk supply. They can be sanitized and used by more than one mother.

Previously used pumps.
Using a previously owned pump that has not been approved for multiple users is like using somebody else's toothbrush. Milk can get into the unsealed motor, even if you get new tubes and personal milk collection parts.

Remember that the average lifetime of a pump is about the same as the length of its warranty. Yes, the pump may work a bit longer than the length of the warranty, but you will have no recourse from the manufacturer if it no longer works efficiently..

There is an even more important aspect to consider. An older pump that is beginning to wear out may not work well. If the pump is not able to adequately stimulate your breasts, then your milk production will drop, and you may not be able to make enough milk to keep up with your baby's needs.

Nothing lasts forever. Pumps wear out. We are not surprised when a hairdryer or a microwave oven or a car fails to work properly after it has reached it's *expiration* date, and it is the same for pumps.

Need more information?
If you want to know more about choosing or using a pump, storing your milk, or if you have other breastfeeding concerns, FREE help is available from Breastfeeding USA Counselors.

All rights reserved by the author and Breastfeeding USA.

Does Your Older Baby Still Need Night Feedings?

Has somebody told you that your baby doesn't need to breastfeed at night past a certain age? This age often varies by advisor. However, science tells us that in many cases, this simply isn't true.

Why? Babies and mothers are different and these differences affect baby’s need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond. This is in part because if their mother has a small “breast storage capacity” and tries to sleep train her baby, her milk production will slow, along with her baby’s growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.

Degree of Breast Fullness
Two basic dynamics are major influencers of milk production. The first, “degree of breast fullness,” refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows. 1The fuller your breasts become, the stronger the signal your body receives to slow milk production.

Breast Storage Capacity
This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need. 3After baby’s first month, a mother with a large storage capacity may notice that her baby:
• Is satisfied with one breast at most or all feedings.
• Is finished breastfeeding much sooner than other babies (sometimes just five minutes).
• Gains weight well on fewer feedings per day than the average eight or so.
• Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average.

Again, what’s important to a baby’s healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a twenty-four-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive. 4For example, a baby whose mother’s breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day. But to get this same 30 ounces (900 mL) of milk, if a mother’s breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day. (This may not apply in the same way to a mother who’s pumping.)

How These Dynamics Affect Night Feedings

How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what’s important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a twenty-four-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby’s weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn't consider either the emotional needs of the baby or his physical need for milk.

References

1. Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis,, Experimental Physiology 81(5), 861-875

2. Cregan, M. D., & Hartmann, P. E. (1999). . Computerized breast measurement from conception to weaning: clinical implications. 89-96 Journal of Human Lact 15(2)

3. Kent, 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 dayPediatrics, 117(3), e387-395

4. Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

Used with permission. Copyright Nancy Mohrbacher, 2012

What About a Sleepy Baby?

All babies sleep a lot in the first days and weeks of life. Some babies certainly are sleepier than others, so how will you know if your baby is too sleepy? And what does “too sleepy” mean?

When you gave birth, there were probably health-care providers around you to help you make sure that your baby woke up often enough to get the milk he needed. Once you are on your own, you may not have anyone around who can help you know whether your baby is feeding well. Because every baby is different, sometimes even experienced mothers cannot always identify a baby who may need some help to feed often enough.

Normal Infant Behavior
First let’s take a brief look at newborns and their sleep patterns, which of course, vary from baby to baby. Newborn sleep has been studied and described for many years. Newborns move through several states: deep sleep, light sleep, a drowsy time, a quiet awake state, an active awake state, and, of course, crying is a “state” as well.1

Most newborns will sleep somewhere between 14 and 18 hours a day in the first weeks, waking frequently to nurse. There really aren’t regular patterns in the life of a new baby. Some babies will wake more frequently than others, with perhaps one longer sleep period. Some will sleep longer between wakings for part of the day, then wake more often to “cluster-feed.” That means that they may nurse several times in a row, even though only a half-hour or an hour has gone by. They may take little naps between those frequent feedings. There is no schedule, no predicting how often a baby will nurse, or how long each sleep period will be. Don’t be surprised if your baby has a longer sleep time of four to five hours every day, or from time to time. That’s also a normal part of an unpredictable schedule. Even a baby’s personality will affect eating and sleeping behavior. There are relaxed, slow feeders who take their fine time, and those who eat quickly and go back to sleep.

Does Your Baby Need to Breastfeed More?
So is your baby too sleepy? Most newborns need to nurse 8-to-12 times a day. (Even 14 or more is not unusual.) Some babies nurse less or more frequently than that, but frequent nursing is needed to establish and maintain your milk supply. 2 If your baby nurses fewer than eight times per day total, that may mean she is too sleepy and needs some helpful stimulation to nurse.

That number of 8-to-12 times a day is a good guide. And new mothers do need to know how to recognize their baby’s early feeding cues, such as any movements (including eye fluttering), hand-to-mouth, and rooting (head turning from side to side with an open mouth). Mothers also need to be aware of techniques they can use to help a sleepy baby feed more often. Your baby may be struggling with the effects of labor medication, a difficult birth, or may be just a little immature.

“Talk, stroke, and woo”3 your baby, says British author Sheila Kitzinger, to bring him closer to wakefulness. That may indeed be a natural and delightful thing for a mother to do. And here’s a list of other tips that have worked for many a mother:

  • Lie back with comfortable support, open your shirt in front, and open your baby’s clothing as well. Put your sleeping baby on your chest, front to front, talk to him, and let your baby rouse and find your breast as he moves from deep to light sleep. Even though he’s sleeping, your baby can nurse effectively.4 Keep your baby lying tummy down on your body as much as possible, as that triggers his inborn feeding reflexes more often. That position, whether in skin-to-skin contact or lightly dressed, helps both of you get ready.
  • Dim the lights or draw the shades so that she can open her eyes.
  • Massage his body or feet, and talk to him.
  • Hold her up vertically face to face and talk...let her hear your voice in that position.
  • Hand express some colostrum or milk onto his lips to stimulate suckling.
  • Put your newborn on his back on a flat surface, and very gently and slowly roll him from left side to right side a few times in a row.
  • Undress your baby a bit. You may have him dressed too warmly.

Even if your baby was wrapped up and “swaddled” in the hospital, it may be better for your baby not to be wrapped up to sleep. Wrapping him can stop his normal responses to nursing and keep him from having access to his own hands and the freedom to move his little body around as he feels like doing. Think about what it might feel like being wrapped up tightly when you needed to move about. It really wouldn’t be too comfortable, but while you could say something about your discomfort, your baby can’t tell you. Light clothing in layers...just one layer more than you are wearing, is a perfect way for him to sleep. And remember to spend time skin to skin with your baby to help his little growing brain mature.

Sometimes you may try to stimulate your baby to feed, but find he is in a deep sleep and unresponsive. He may be so totally relaxed that you can pick up his arm, let go, and it just drops. If that is the case, you may want to wait until his sleep state changes. In 20 minutes or so, try the stimulation techniques again, since newborns move in and out of deep sleep more often than adults. You may be able to rouse him more easily after some time has passed.5 He may be ready to eat the next time you try. You will learn how to stimulate your baby, as you watch him and learn more about him. As he matures, he will wake to nurse on his own unique schedule. You will find that once your sleepy baby takes a few good mouthfuls of your milk, she will become interested in getting more of that lovely, tasty stuff.

If, however, you have continuing concerns about getting your baby to feed, consider reviewing the signs that tell you that your baby is getting enough to eat. He should be having four yellow, seedy poopy diapers by Day 4 and your breasts should feel noticeably fuller.6 Your newborn should seem to be comfortable at your breast, relaxing body and hands as the feeding progresses, and let go of the breast by herself after a feed. If your baby is gaining an average of an ounce a day or more, he is doing well. Your care provider can reassure you that your baby is indeed getting a good amount of milk if his weight gain is within the normal range. If these signs are not there, no matter how long or briefly your baby sleeps, quickly get help from a board-certified lactation consultant or your health-care provider. An underfed or dehydrated baby can be very sleepy and not nurse well even when he wakes often.

Each baby is unique. While some mothers worry that their baby isn’t sleeping regularly enough during the early weeks and months, you may have concerns that your baby is too sleepy. Experience has shown, however, that most babies develop more of an established sleep pattern after the newborn period. Enjoy this special time with your baby.

References
1 Brazelton, T.B., & Nugent, J.K. (1995). Neonatal behavioral assessment scale. London, UK: MacKeith Press.
2 Mohrbacher, N. & Kendall-Tackett, K. (2010). Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers. Oakland, CA: New Harbinger Publications.
3 Kitzinger, S. (1989). Breastfeeding Your Baby, New York: Alfred A Knopf.
4 Colson, S., DeRooy, L., Hawdon, J. (2003). Biological Nurturing increases duration of breastfeeding for a vulnerable cohort. MIDIRS Midwifery Digest 13(1), 92-97.
5 Richardson, H.L., Walker, A.M. & Horne, R. S.C. (2010). Stimulus type does not affect infant arousal response patterns. Journal of Sleep Research, 19, 111-115.
6 Nommsen-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. J Hum Lact, 24(1), 27-33.

© Copyright Breastfeeding USA, Inc. 2012 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.

To Pump More Milk, Use Hands-On Pumping

Would you like an effective method for pumping more milk? Until 2009, most of us assumed that when a mother used a breast pump, the pump should do all of the milk-removal work. But this changed when Jane Morton and her colleagues published a ground-breaking study in the Journal of Perinatology.1 The mothers in this study were pumping exclusively for premature babies in the hospital’s neonatal intensive care unit.

For premature babies, mother’s milk is like a medicine. Any infant formula these babies receive increases their risk of serious illness, so these mothers were under a lot of pressure to pump enough milk to meet their babies’ needs.

Amazingly, when these mothers used their hands as well as their pump to express milk, they pumped an average of 48 percent more milk than the pump alone could remove. This milk also contained twice as much fat as when mothers used only the pump.2 In most mothers exclusively pumping for premature babies, milk production falters after three to four weeks.3 But the mothers using this “hands-on” technique continued to increase their milk production throughout their babies’ entire first eight weeks, the entire length of the study .

Hands-on pumping is not just for mothers with babies in special care. Any mother who pumps can benefit from it. How does it work? To do hands-on pumping, follow these steps:

  1. First, massage both breasts.
  2. Double pump, compressing your breasts as much as you can while pumping. (Search “hands free pumping” online for pumping bras or bustiers that fit any brand of pump and allow you to double pump with both hands free.) Continue until milk flow slows to a trickle.
  3. Massage your breasts again, concentrating on any areas that feel full.
  4. Finish by either hand expressing your milk into the pump’s nipple tunnel or single pumping, whichever yields the most milk. Either way, during this step, do intensive breast compression on each breast, moving back and forth from breast to breast several times until you’ve drained both breasts as fully as possible.

This entire routine took the mothers in the study an average of about 25 minutes. For a demonstration of this technique, watch the online video “How to Use Your Hands When You Pump” at: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html.

These three online videos are examples of three different hand-expression techniques that some mothers have found helpful and can be used as part of hands-on pumping: http://ammehjelpen.no/handmelking?id=907 (scroll down for the English version), http://video.about.com/breastfeeding/Hand-Expression-Technique.htm and http://newborns.stanford.edu/Breastfeeding/HandExpression.html. See also the article Hand Expression on the Breastfeeding USA website.

Hands-on pumping can be used by any mother who wants to improve her pumping milk yield or boost her milk production. Drained breasts make milk faster, and hands-on pumping helps drains your breasts more fully with each pumping.

References
1Morton, J., Hall, J. Y., Wong, R. J., Thairu, L., Benitz, W. E., & Rhine, W. D. (2009). Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology, 29(11), 757-764.
2Morton, J., Wong, R. J., Hall, J. Y., Pang, W.W., Lai, C.T., Lui, J., Hartmann, P.E., & Rhine, W. D. (2012). Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology, Jan 5. doi: 10.1038/jp.2011.195. [Epub ahead of print]
3 Hill, P. D., Aldag, J. C., Chatterton, R. T., & Zinaman, M. (2005). Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants. J Hum Lact, 21(2), 138-150.

added links to references and studies.

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