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Ask An LC: What About Pumping?

Wed, 23 Sep 2009 03:46:59 +0000

Welcome to “Ask an LC” by Melissa Yetter RN CLC

Melissa Yetter RN CLC is an experienced OB/L&D/Newborn nurse since the 70’s. She started her specialized lactation career in 1988, became a CLC in 1991, and went on to IBCLC in 1993, renewed in 1998. Due to unforeseen circumstances, she opted out of the required 10 year IBCLC recertification exam in 2003. She has always maintained CLC status. She recently recertified for CLC (Certified Lactation Counselor) in 2008. She blogs at “Stork Stories… Birth & Breastfeeding” about her experiences as a maternity nurse and lactation professional from the 1970’s to present.

Great Questions:

@rotormommy – I have to go back to work at 6 weeks. When should I start pumping and having my husband feed her so I can still BF when I’m home?

@TheMomCrowd – Q: I would like to pump, but then I am empty when baby wants to eat. If I feed pumped milk what’s the point? I don’t make extra.

photo credit: Amber Slatosky

What About Pumping?

If you plan to supply your own milk when you are away from your baby either for an occasional outing or returning to work/school outside the home, you’ll need to decide how you will express your milk into a container to feed to the baby. Although the use of a breast pump is the most popular, hand expression can also be very effective and quite cheap for those who don’t wish to use a pump. It is also a valuable skill to learn. Your hands are always with you! Most of what I discuss may be about the use of a breast pump as a tool for milk expression; those of you who hand express can still use some of this information for your situation. It should also be mentioned that regular expression to help initiate or improve a low milk supply [Link] is different from these questions asked above. These will be answered with an understanding that there is already an established milk supply.

I have found it’s important for mothers to understand that pumping is a substitute for the real thing and that it takes practice for lots of moms. I always say to expect hardly anything the first time you try then whatever milk you may get is wonderful! One very important point to realize is that whatever you see come out with a pump or hand expression is NOT a reflection of how much a baby gets in a feeding when he is well latched and effectively feeding. What you see come out with the pump is what your body released at that moment in time. Even women with a great supply and healthy growing babies can have trouble learning to pump. The baby is the master …you are merely trying to imitate him! The type of pump used and when you pump in relation to the age of the baby as well as the time of day, frequency etc. can have a big impact on your results.

The general rule is: More Out means More Made. (Morbacher) The more milk drained from the breast- the more milk the breast will make!

What Kind of Pump?

How Long Will You be Away From Your Baby?

Regular intervals…such as work full or part-time.

It is important for this to be as efficient, comfortable and convenient for you as possible to make this work. Your goal may be to keep your supply up while away from your baby or to provide all of your baby’s nutritional needs thru your own milk. The best advice is to either rent a high quality pump or purchase an electric pump with at least 40 to 60 suction/release cycles per minute. Faster frequencies (up over 100) are not necessarily associated with improved results or higher volumes of milk. [Link] Cycles fewer than this though are associated with a gradually decreasing supply. When you think about your goal, and you think about the cost of a quality pump, remember that formula could cost you up to around $200-$250 per month!!! A quality pump is a good investment!

Minimal Part-time work or occasional separation.

If you have the budget, any type of pump described above is wonderful! You may also be just fine with a less expensive pump or one with fewer cycles per minute. You could do fine with a good cheaper, manual pump. Many manual or battery operated pumps have an automatic suction release feature which can be convenient. Battery pumps without an AC electric adaptor can go through batteries quickly depending on the pump. Also, the highest suction setting doesn’t always help you get the most milk. Your milk flows most when you have a “let-down”or milk release, not because of constant suction. Without a letdown, a lot of milk can stay in the breast. The pump should have a suction control. Set the pump at the strongest setting that is comfortable for you. It should not hurt!

I have purposefully NOT listed any particular pump so as not to endorse any product. I would recommend you read the info on each pump you are interested in and do your homework for your specific needs.

When Should You Pump?

If you are getting ready to go back to work or school.

When a mother needs or wishes to return to work by 6 – 8 weeks after the baby is born, as asked above, and wishes to “build up a stock-pile of milk,” it is recommended she begin pumping after breastfeeding is well established around 3 weeks of age. If you are going back to work/school later than that, you could start the process about 2-3 weeks before going back. We usually suggest practicing pumping for the first time in the morning hours about an hour or so after a baby feeds. There seems to be a naturally higher volume of milk during morning hours as opposed to evening. Scientists think this may be due to higher prolactin (the milk-making hormone) levels in the middle of the night. Many times at around 3 weeks, the breasts are still feeling full a lot of the time and there could be some re-accumulation of milk in the breasts from the last feeding so mom can have better results with practice. If you are still worried there won’t be milk available for your baby when he’s ready, you can try practicing pumping on justone breast. Another good time to try is if your baby seems to have a longer nap than usual. Some moms have liked to pump just a little several times during a day, storing each in fridge and then combining when cooled.

Once you practice in the morning, you may also be able to get your body to respond to the pump at other times during the day. Practice, practice, practice and be patient with yourself. Trust your body. You can learn to do this if it is important to you! Some moms are lucky and need very little practice. For others, it may take awhile. Once you have returned to work, the best way to maintain your supply would be to pump every time the baby would be feeding. There are many moms who aren’t able to pump that often at their jobs, and still work out a balance between work and home. Some moms feed the baby much more often when at home and the baby ends up not needing many feedings while you are away. The need for frequent pumping doesn’t last forever. It is more important for young babies under 3 months. As the baby gets older, you can usually space it out and when he begins solids by 6 months or so, some moms can really decrease the amount of pumping needed while away, and focus on a lot of breastfeeding when together. The main key principle is supply and demand or the more milk going out of the breast equals more milk made. Your personal goals and motivation to meet those goals will help determine what you do.

If you are getting ready for an occasional time away from breastfeeding.

Maybe you are going to an event like a wedding or just need someone to feed your milk to your baby for a different reason. Perhaps you or your baby is unable to nurse temporarily due to illness. [Link] The principles of practicing to pump in the morning or an occasional longer nap as described above should still help you. Many moms have found it easy to express from one breast while the baby nurses from the other (if you only need one hand for each. It can be very beneficial to take advantage of the letdown stimulated by the baby. If you have the time and it’s imortant to you then you should beable to make it work. Sometimes an event can occur suddenly like an ill family member and you don’t have time to practice. This can be stressful for you and the last thing you need is uncomfortable full breasts! It is possible to try relaxation techniques, warm compresses, breast massage, smell a blanket or clothing from your baby or just thinking about the baby to help you pump or express. You can even go into a private restroom and express both full breasts into a sink to relieve yourself.

After I Pump What About That Empty Feeling?

Anytime mom feels like her breasts are feeling empty, we first have a quick look at the whole picture to evaluate if this is normal breast changes through the experience and evaluate whether her supply is good and the baby’s weight gain adequate. There may be moms with great supplies who experience their breasts feeling empty after they begin pumping. They wonder if there will be any milk to now feed the baby. This is a very common concern- you are not alone. It is a misconception or myth that full breasts make more milk. Full breasts actually create pressure in the breast which tells the breast: “Hey–we aren’t using this milk… its backing up–so stop making it!” When the breasts are drained or emptied more often, the message is: “Hey—they are using this milk up like crazy! Keep making more –increase the product!”There is also usually a lot of milk made on the spot for any given feeding.

When a mother first starts pumping, it may take a few feedings to adjust to more milk taken out of the breast. When a mother has to use a pump on a regular basis, it may take a few days for the breasts to get used to the change. It usually takes a few days for the breasts to respond to the increased need during periods of rapid growth, frequency days or when a mom needs to increase her supply because it is low. [Link]

Even after being reassured this could be normal, some babies are used to a quick flow of accumulated milk at the beginning of a feeding and may act upset if the milk doesn’t seem to come out as quickly right in the beginning of the feeding as they are used to. If you have this situation, it may be best for you to try practicing pumping on just one breast; or for short periods throughout the day and combine your results after cooled. Give your body some time to adjust and it can work.Follow your heart. If you really want to provide your own milk for your baby when you are not together for whatever the reason, you can do it! I have worked with two different flight attendants who returned to work with babies under the age of 5 months. They were both able to maintain a supply even when away for 4-5 days at a time. Each handled things their own way and each felt very successful!

Whatever your situation or whatever your goals; you CAN still make breastfeeding work! Enjoy your baby!

References:

Various links throughout post

Additional references:

Center for Breastfeeding Education, Healthy Children’s Project: Course Syllabus; Lactation Counselor Certificate Training Program; Ft. Collins, Colorado; October 2008

Cadwell K, Turner-Maffei C.: Pocket Guide for Lactation Management. Jones and Bartlett Publishers, Inc, Sudbury, MA 2008

Kent JC, Ramsay DT, Doherty D, Larsson M, Hartmann PE.: Response of breasts to different stimulation patterns of an electric breast pump. J Hum Lactation. 2003 Aug;19(3):269.

Mitoulas LR, Lai CT, Gurrin LC, Larsson M, Hartmann PE: Efficacy of breast milk expression using an electric breast pump. J Hum Lactation. 2002 Nov;18(4):344-52

Morbacher N, Kendall-Tackett, K: Breastfeeding Made Simple. New Harbinger Publications, Inc , Oakland, CA 2005

Ask An LC: About Breastfeeding with Raynaud’s Disease

Wed, 02 Sep 2009 14:56:06 +0000

Welcome to “Ask an LC” by Melissa Yetter RN CLC

Question:

“@clementinenw – Would love to see info. on dealing with Raynaud’s disease while breastfeeding. Especially if conventional wisdom doesn’t help enough.”

I hope I can be of help to you. This is a painful situation. Dealing with Raynaud’s disease is very difficult especially while breastfeeding. The question implies that this mother (whether it is yourself or a mother you are helping) has tried some conventional options to find relief. I’m not certain what has already been tried so I’ll provide you with all that I’ve found.

What is Raynaud’s?

Many people haven’t ever heard of Raynaud’s phenomenon. This condition usually affects women from about 20 to 50 years of age. This is a situation where there is an abnormal spasm of arteries supplying blood to the fingers or toes, closing off blood supply and causing numbness, burning, tingling, pain- sometimes very intense pain and a temporary loss of color (blanching, pallor, waxy white). The skin of the affected area can also turn blue from lack of oxygen. When the circulation returns, there is sometimes a temporary flushing before returning to normal. The normal skin color goes from white to red, or raspberry to normal, or white to blue to red, or raspberry to normal.

It is this biphasic or triphasic color change that helps in the unique diagnosis of Raynaud’s. The triggers which usually set off the vasospasm are cold or rapid temperature changes and sometimes emotional stress. For some women, Raynaud’s affects the nipple whether or not she may be pregnant or breastfeeding. At a conference, I heard of a family of women that never wanted to swim because of the painful blanching of their nipples. The poor young ladies thought this happened to all women and didn’t understand how other girls could stand it for swimming!

Raynaud’s of the nipple in breastfeeding women is usually described as excruciating nipple and breast pain after nursing, pumping /expressing milk and at other times when the nipple is cold or wet. It is always associated with the biphasic or triphasic color change. Sometimes the areola can also change shape while this is happening. Not all women who experience nipple blanching and pain have Raynaud’s phenomenon. However it can be misdiagnosed as nipple vasospasm for other problems such as poor latch or confused with pain from yeast or Candida albicans infections. It can also happen simultaneously with other breastfeeding problems. It is always important to get evaluated by your medical provider or Lactation professional.

What can you do?

If a breastfeeding mother has been diagnosed with Raynaud’s, there are a few things you can try to keep you as comfortable as possible. Treatment is directed towards making certain breastfeeding is optimal and reducing situations or conditions which predispose you to the symptoms. Most women with painful breastfeeding need immediate pain relief to continue breastfeeding. It then becomes very important to suggest/ offer treatment options or plan that will help alleviate the pain quickly:

Optimal positioning and latch on techniques are crucial to help avoid / eliminate any other causes of nipple pain.
Reduce exposure to cold … besides the climate, this includes avoiding cold stimuli and quick temperature changes of the nipple.
After feeding, some mother’s keep a warmed cloth nearby to place on the nipple immediately after released from baby’s warm mouth. This allows for a more gradual temperature change back to normal.
Reduce emotional stressors as much as possible.
Avoid smoking or tobacco in any form including secondary smoke.
Avoid alcohol use which can exacerbate symptoms.
Avoid or limit caffeine as this can exacerbate symptoms.
Avoid certain drugs like pseudoephedrine, beta blockers, oral contraceptives (Hale 1999).
Some have found relief with aerobic exercise, and dietary supplements such as Evening Primrose Oil or Fish Oil over time (6 weeks) but no immediate results have been reported.
Nifedipine, (Procardia) a calcium channel blocker, (high blood pressure medicine) has been prescribed and used to treat Raynaud’s symptoms with good results because of its vasodilator effects. (Anderson 2004)
Anderson 2004 reports all mother’s who chose to try this medication reported prompt relief of pain.
Nifedipine doses according to Hale for this situation would be in a sustained release form providing 30 – 60 mg per day.
Nifedipine is listed in Hale 2008 as “L2” Safer. He lists “none” for any pediatric risks or concerns while the mother’s are on the medication. Also listed with the AAP as “Usually compatible with breastfeeding.”

Sometimes a mom may not know what exact answers to give to medical questions or the professional may not ask the right questions… therefore the diagnosis of Raynaud’s can be elusive. It may not be initially associated with her nipple pain. We as professionals need to widen our range of questions. For instance: “Does the mother have any symptoms associated with Raynaud’s phenomenon?” “Does the mother have color changes in her nipples after breastfeeding?” Taking steps like this can possibly help us pinpoint this diagnosis sooner if it is truly the case.

References:

Various links throughout post

Additional references:

Hale, Thomas: Medications and Mothers’ Milk 2008, 13^th edition; Hale Publishing, Amarillo, TX 2008

Hale, Thomas: Clinical Therapy in Breastfeeding Patients 1^st ed. Pharmasoft Medical Publishing, Amarillo, TX 1999

Center for Breastfeeding Education, Healthy Children’s Project: Course Syllabus; Lactation Counselor Certificate Training Program; Ft. Collins, Colorado; October 2008

Cadwell K, Turner-Maffei C.: Pocket Guide for Lactation Management. Jones and Bartlett Publishers, Inc, Sudbury, MA 2008

Anderson JE, Held N, Wright K. Raynaud’s phenomenon of the nipple: a treatable cause of painful breastfeeding. Pediatrics. 2004 Apr;113(4):e360-4 Abstract accessed via Pubmed.gov August 2009

Ask a LC: How to increase milk supply with galactogogues and over-the-counter herbs

Wed, 19 Aug 2009 15:14:21 +0000

Welcome to “Ask a LC” by Melissa Yetter RN CLC

“@birthserene How about tips for how to increase milk with galactogogues and OTC herbs?”

Thank you for this great question!

Low milk supply is one of the most common reasons why mother’s say they have decided to stop breastfeeding. Occasionally, mothers will look for an answer to their supply problem with Galactogogues (sometimes called lactogogues). These are types of medication, food or herbal substances believed to help initiate, maintain or enhance a mother’s milk supply.

The experts agree that any time a mother feels she needs help with milk supply, it is so very important that before she considers taking any of these substances; she should get help to figure out why the supply could be low. It is most common that a mother’s supply may be low due to management or technique which can possibly be turned around quickly.

FIRST- Please get qualified help to fully evaluate your situation as I discussed in this post. Milk supply can decrease if the breasts are not regularly and frequently emptied. Milk supply generally will increase if there is an increase in the frequency and complete draining of the breasts. No medication can take the place of full evaluation and each individual should be fully counseled on what options may best be suited for her situation.

SECOND- As with all medications, any over the counter herbal preparations should be discussed with both your doctor and your baby’s doctor BEFORE taking to rule out any health concerns. Close follow-up and support for both mother and baby is very important.

In my current practice, I usually discuss many options with them and send them to LC’s working outside the hospital for the full evaluation and plans, and point them to some of the excellent references you’ll see throughout this post. While I’ve worked with mother’s taking Reglan and Fenugreek, I have had limited experience working with mothers taking these other preparations.

The following highlights I’ve compiled on many of the common galactogogues are important to know from an LC’s perspective, or point of view.

I will briefly define two of the common medications and then outline some of what I’ve found on the most common herbal preparations. I am very happy to provide this information and hope it’s clear I’m not making any specific recommendations.

Prescription Medications:

Metoclopramide (Reglan)

· Most commonly used medication as galactogogue in the United States, well studied

· Prescription only and should be followed up by LMP (Licensed Medical Provider)

· Action is that it suppresses or antagonizes dopamine (a prolactin inhibitor) in the central nervous system (CNS) which then helps increase prolactin levels

· Gastrointestinal stimulant, used as an anti-nausea medication and as treatment for reflux in infants

· Usual dose is 30 to 45 mg per day divided into 3 or 4 doses

· Response of increased milk is dose related and individualized

· Regimen is usually taking a full dose for 1 to 2 weeks then taper off over about a week

· Side effects (SE) usually mild: diarrhea, sleepiness, fatigue, restlessness.

· Possible rarer SE where stopping the drug should be considered include: anxiety, agitation, sleeplessness, dizziness, confusion, headache, depression.

· Found to be present in milk but hasn’t shown side effects in infants.

· Listed as L2 “Safer” in Hale 2008

Domperidone (Motilium)

· Similar to Reglan in action, also used to control nausea and reflux

· Not commercially available in the USA, surrounded by controversy here despite reported safe track record and still not fully FDA approved

· Prescription only and should be followed up by LMP (Licensed Medical Provider)

· Regimen usually 10 to 20 mg three to four times per day taken for 3 to 8 weeks. Dr. Newman has sometimes suggested higher doses. Link

· Response individualized, some show improvement with in 24 hrs, others need a couple weeks

· SE mild and uncommon, include: dry mouth, thirst, rash, itchy, headache

· Unlike Reglan, this doesn’t enter the brain compartment and has less risk of CNS Side Effects

· According to Hale 2008, “considered the ideal galactogogue” listed as L1 “Safest”.

Natural or Herbal Galactogogues

Historically, women have used natural foods and herbs to help their milk supply. Many times these substances have not been scientifically evaluated however through the “test of time” these have been passed through generations as “safe” according to tradition. How these herbs actually work is not always known. The common commercial herbal teas are considered relatively safe for most mothers however for other uncommon substances, safe quality may be questionable. Some over the counter preparations haven’t been fully studied.

It is important to mention that the FDA does not inspect these dietary supplements and some may really vary in composition. There may also be a concern over fraudulent or toxic substances. Please be careful of who supplies and manufactures the product. It is always a good idea to find the most information possible before deciding to start taking one.

Some of the herbs most commonly used as galactogogues are fenugreek, goat’s rue, and milk thistle. Others reported include: fennel seed, blessed thistle, alfalfa, anise, nettles, caraway seed, dill, basil and red clover. One of the favorite sources I have for searching on botanicals and herbs in Lactation is Dr. Tieraona Low Dog. I had the great pleasure of hearing her speak at the ILCA conference in 2006. Here is a link to her website and link to a great article on alternative therapies by Dr. Low Dog.

Fenugreek (Trigonella foenum-graecum)

· Most commonly recommended herbal galactogogue, widespread good reputation but not clearly documented

· One of oldest medicinal herbs. Sold as a spice, dried seed or extract and is a member of the pea family

· Historically used in India and Middle East

· Extract also used as flavor for artificial maple syrup

· Listed as GRAS (Generally Regarded As Safe) by the U.S. Food and Drug Administration

· Usual dose is one to four capsules (580–610 mg) three to four times per day, although there is no standard dosing. Huggins [LINK] recommends 2 or 3 capsules 3 times/ day.

· The higher of these doses may be required in relactating or adoptive mothers.

· Alternative dosing- can be taken as one cup of strained tea three times per day (¼ tsp seeds steeped in 8 oz water for 10 minutes).

· Huggins (above) reported the anecdotal use of fenugreek in at least 1200 women with increased milk supply within 24 to 72 hours.

· Reported side effects are rare: maple syrup like odor to sweat, milk, and urine; diarrhea; and increased or exaggerated asthma symptoms.

· Not recommended for use during pregnancy because of possible stimulant effect on uterus.

· Higher doses of Fenugreek also known to cause hypoglycemia (low blood glucose), so caution is advised.

· Hale 2008 Lists as “L3” Moderately Safe. {No controlled studies in breastfeeding women, however risk of untoward effects to breastfed infant is possible or controlled studies show only minimal …adverse effects}

Goat’s Rue (Galega officinalis)

· Traditional galactogogue, recommended widely in Europe, based on studies in 19^th century early 20^th century which support increased milk supply when fed to animals

· Used in veterinary medicine. No controlled human clinical studies trials have ever been done

· Despite a large following, not a lot of data to document use, effectiveness, or to report side effects

· There have been no adverse events reported in Europe or South America, where the herb is also used as a hypoglycemic (to lower blood sugar) agent.

· One source (Rosti) reports adverse effects of drowsiness, hypotonia (low tone), lethargy, vomiting, and poor suckling in two breastfed neonates after maternal ingestion of a combination product. A lactation tea containing extracts of licorice (Glycyrrhiza glabra), fennel, anise, and goat’s rue. The symptoms resolved when stopping the tea combined with a 2-day temporary break from breastfeeding. (Tea never tested for contaminants.)

· It is usually used as a tea (1 tsp dried leaves steeped in 8 oz water for 10 minutes) with 1 cup taken three times a day.

· Not listed in Hale 2008

Milk thistle (Silybum marianum)

· Historically , many thistles used as lactogogues.

· No restrictions on the use of seed for tea by any authority

· Often used throughout Europe, but there had not been randomized controlled trials to validate effectiveness

· 2008 study by Di Pierro et al studied 50 healthy women, dosages of 420 mg Silymarin/ day (a Silybum marianum standardized extract) with reports of increased milk volume when treated for 60 + days

· Di Pierro et al conclude Silymarin may be considered as a safe and effective herbal product that can be orally administered in order to improve the daily milk production in healthy women after delivery, without affecting milk quality.

· St. Mary’s thistle is still a common name for the plant in honor of the Virgin Mary.

· Early Christian belief that the white colored veins in the leaves were symbolic of her breast milk.

· The American Herbal Products Association gives it a rating of 1, meaning that the herb may be safely consumed when used appropriately and does not contraindicate its use during lactation

· It is often used as a strained tea (simmer 1 tsp crushed seeds in 8 oz water for 10 minutes) taking two to three cups per day

· Listed as “L3” Hale 2008

Additional Substances

· Fennel Seed— Used as flavoring spice, medicinal herb. Has no modern evidence of lactogogue effect. Common use in infant colic. (Low Dog)

· Alfalfa— Historically used as a lactogogue. Nourishing with calcium, potassium, and vitamin K. No known or reported safety concerns with normal use of alfalfa leaf . (Low Dog)

· Nettles— Historically used as a lactogogue. Very nutritious food- herb. Freeze dried nettle is said to be anti-allergenic. No known safety concerns or issues with nettle leaf. (Low Dog)

· Red Clover— Flowers have been traditionally used as lactogogue. Has been used as an expectorant. The leaves are rich in phytoestrogens and are popular for menopause. There are no known safety issues with flowerheads. (Low Dog)

CONCLUSION

There are various options for mothers who find themselves in a situation with low milk supply. From a professional standpoint, it is highly recommended to have a proper evaluation before considering any galactogogue. As always, get the best information possible, weigh your options and make the best choice for you.

If you have a question for Melissa please use the contact form at the top of this homepage. You can also send it via Twitter to @bfmom.

Please remember that since each actual mother-baby breastfeeding relationship is unique, some specific questions or situations are not easily answered unless the mother/baby are physically observed, examined, or seen in person. In this format, it’s best to answer questions which are more general in nature. As always, check with your health care provider for specific concerns about your baby’s or your own health.

Melissa Yetter RN CLC is an experienced OB/L&D/Newborn nurse since the 70’s. She started her specialized lactation career in 1988, became a CLC in 1991, and an IBCLC in 1993. In 2003, due to unforseen circimstances, opted not to sit for the required 10 year IBCLC recertication exam but maintained LC status. She recently recertified for CLC (Certified Lactation Counselor) in 2008. She blogs at “Stork Stories… Birth & Breastfeeding” about her experiences as a maternity nurse and lactation professional from the 1970’s to present.

References:

Various links throughout post

Additional references:

Hale, Thomas: Medications and Mothers’ Milk 2008, 13th edition; Hale Publishing, Amarillo, TX 2008
Center for Breastfeeding Education, Healthy Children’s Project: Course Syllabus; Lactation Counselor Certificate Training Program; Ft. Collins, Colorado; October 2008
Low Dog T: Botanicals and the Breastfeeding Woman: A Review of the Evidence. Presentation at International Lactation Consultants Association (ILCA) Annual Conference, August 2006.
The Academy Of Breastfeeding Medicine: “Protocol #9: Use of galactogogues in initiating or augmenting maternal milk supply” accessed 8/2009 at http://www.bfmed.org/
Rosti L, Nardini A, Bettinelli ME, Rosti D: Toxic effects of an herbal tea mixture in two newborns. Acta Pediatr 83:683, 1994.
Di Pierro et al: Clinical efficacy, safety and tolerability of BIO-C®(micronized Silymarin) as a galactogogue. Acta Biomed. 2008 Dec;79(3):205-10. Abstract accessed via Pubmed.gov August 2009

Ask An LC: About Milk Supply

Wed, 12 Aug 2009 03:53:03 +0000

All questions are so very very important. Especially breastfeeding questions! Never, ever do I hear a “stupid” question, although many new moms could feel like their questions may be silly or stupid and are then are afraid to ask. As a Health Care Professional (HCP) and Certified Lactation Counselor, I want you to know that the very questions moms or dads ask are the ones which help me learn how to help them best, what their true concern is, or realize how to be clearer in my answers so they really understand. Many times I’ve learned that the first question a mom asks may not be what she really wants to ask. To help define a mother’s actual concern, I must first listen carefully to what she is asking and ask her a few more questions. Then I try to provide her with the information she wants in a non judgmental way so she can make the best informed decisions possible for her own breastfeeding situation. My goal is always to support the mother.

I hope I can meet with your expectations and answer some of your questions in this new forum! Don’t be afraid to ask! Please keep in mind that since each actual mother-baby breastfeeding relationship is unique, some specific questions or situations are not easily answered unless the mother/baby are physically observed, examined, or seen in person. In this format, it’s best to answer questions which are more general in nature. As always, check with your health care provider for specific concerns about your baby’s or your own health.

Questions about Milk Supply

@notdiyheather “ How do you help moms understand that their bodies WILL make the milk needed? I hear that all the time re: no milk supply”

Excellent question!! I take this as a question from someone who may help other moms so I’ll approach it that way. This type of milk supply question goes hand in hand with what is perhaps the number one question new mothers have: “How do I know the baby is getting enough milk?”

Helping new moms understand how to evaluate the adequacy of feedings and teach them to look at the overall picture, a 24 hr day and general health of the baby, is of the utmost importance. Most moms will make the needed amount of milk, given proper management.

Many times, concerns about inadequate milk supply are based on a mother’s perception that she doesn’t have enough or can’t make enough milk. This is fairly common due to a multitude of issues, but mainly lack of proper education. Sometimes her friend’s and or family’s comments spark this concern.

I have learned that in most breastfeeding situations, whatever the concern, I try to expect that the situation and the answer will most likely be simple. It can be a simple correction of breastfeeding management practices or techniques. Mothers need to know the basic foundation: Proper latch, quality feeding activity and frequency, producing adequate output, and weight gain for a thriving healthy baby. When you see a deviation from the simple, normal or common, then further exploration is needed to actually identify the root or cause of the situation.

All questions about milk supply concerns should be taken seriously and not be given a “standard” answer until we determine that the baby is indeed feeding adequately with good milk transfer and the milk supply is adequate. Sometimes at first glance or from a distance, many situations of the perception of insufficient milk versus actual insufficient milk can look similar.

When the mother says she is afraid she doesn’t have enough milk or asks how she can know the baby is getting enough milk I do the following:

I always start with telling her she is not alone. She is asking the #1 question new parents ask!
Rule-out any actual problems of supply issues by trying to determine the adequacy of feeding and milk transfer:
- What causes your concern about not making enough milk?
- Right from the start, colostrum (the “newborn milk”) is the ideal food and adequate for the baby.
- Does your baby feed with good energy at least (minimum) 8 times in 24 hours? More often is common and encouraged especially in those early days.
- Do you see bursts of rhythmic sucking/drinking with swallowing at each feed?
- Do you see expected output patterns for age? (according to the AAP 2005) ~3–5 urines and 3–4 stools per day by 3–5 days of age; 4–6 urines and 3–6 stools per day by 5–7 days of age~ with urines continuing to be lighter, clearer and increasing volume. The stools should be mostly yellowish in color by the 4^th to 5^th day.
- The baby’s weight should be down no more than 7% from birth and regained before 2 weeks of age. Then there should be a weight gain of at least ½ to 1 ounce per day in the early months (most healthy breastfed babies gain more than that daily on average).
- These are safe parameters or guides … if the baby is outside these ranges; an observational evaluation should be made by a Lactation professional.
Once established that baby and mom are within the normal ranges, find out what she knows about and help her understand the keys to breastfeeding success and the process and science behind milk production. Simplify these as best you can for the mother.
- Early and frequent removal of milk from breasts.
- Lots of skin to skin time right from birth.
- Infant feeding cues – state of readiness – best motor coordination (crying is a late sign of hunger).
- Adequate comfortable asymmetrical latch with good seal/good suction.
- Nipple stretch. It is important that the nipple lengthens to maximize release of oxytocin.
- Adequate sucking rhythm: 2 sucks to 1 swallow or 1 suck to 1 swallow
- Milk transfer speed. The faster milk is removed from breast and transferred to baby, the higher the fat content is in milk. There is a faster short-term milk synthesis and faster wash down of fat globules.
- Satisfaction signs in baby (drunk on milk).
- Adequate stools. Urine output indicates hydration and stool output is a better tool or indicator of adequate calories from milk, especially in the early days and weeks.
- Encourage a weight check visit even if only for her piece of mind…. Once I suggested that to a mom who was certain she did NOT have enough milk at one week. Her baby was already 9 oz over birth weight!!
If her milk supply is indeed below what it should be, there is a lot of good information out there to help guide the mother, the first being an evaluation by a Lactation professional and visit to the baby’s HCP and possibly the mother’s HCP.

As I always say, give the mother proper information and then support her decisions. Allow her to make her own decisions about which solutions she may choose to work on based on her situation.

Never underestimate a mother’s desire to breastfeed her infant
Never overestimate a mother’s desire to breastfeed her infant
Support the mother, support the mother and most of all… support the mother

Bear with me as I am going to tie in the next question because a lot of the same information applies about evaluating normal, perceived inadequate and an actual problem. There is also a correlation between proper breastfeeding management from the beginning (described above) to help avoid this situation.

@Trevieness “So many people I know say their milk hasn’t come in? I always wonder if that’s really true but why would they if it’s not?”

Another excellent question! It is possible that some of these friends or people you are helping never noticed their milk “coming in.” This is many times true if the mother pays attention to the baby’s feeding needs only, nurses very frequently and her breasts do not have the occasion to become noticeably full. This is especially true with second and third time lactating moms. Of course this is looking at the situation from a simple/normal angle provided all the above parameters are met.

On the other hand, there can be a delay in lactogenesis (actually Lactogenesis II, the onset of copious milk secretion) for various reasons. This should happen by the 4^th postpartum day and sometimes a little later if there was a delay in stimulation and infrequent removal of colostrum from the breast. This may be due to poor breastfeeding management advice, an unidentified/unresolved inadequate feeding pattern, giving the baby formula, or the baby is sick and not able to feed, accompanied by lack of pumping/expressing in place of those missed feeds. There have also been reports of very stressful deliveries, or uncontrolled/poorly controlled diabetes playing a role. (These are usually accompanied by the above, not to mention feeding formula for hypoglycemia). There is also the possibility of retained placental fragments inhibiting lactogenesis. These situations have been listed from most often to least often seen in my experience. There may be additional factors depending on the mother’s (hormonal imbalances) or babies health. There is the rarer situation of true Insufficient Glandular Tissue (IGT),however, I doubt you are talking about that since you said “so many people I know.”

Thanks so much for this opportunity! I look forward to more questions!

Melissa Yetter RN CLC is an experienced OB/L&D/Newborn nurse since the 70’s. She started her specialized lactation career in 1988, became a CLC in 1991, and an IBCLC in 1993. In 2003, due to unforseen circimstances, opted not to sit for the required 10 year IBCLC recertication exam but maintained LC status. She recently recertified for CLC (Certified Lactation Counselor) in 2008. She blogs at “Stork Stories… Birth & Breastfeeding” about her experiences as a maternity nurse and lactation professional from the 1970’s to present.

References:

Cadwell, Turner-Maffei: Pocket Guide for Lactation Management; Jones and Bartlett, MA. 2008

AAP, Section on Breastfeeding: Breastfeeding and the Use of Human Milk ; Policy Statement 2005 PEDIATRICS Vol. 115 No. 2 February 2005, pp. 496-506

Neville, Morton: Physiology and Endocrine Changes Underlying Human Lactogenesis II; J. Nutr. 131:3005S-3008S, November 2001