Tuesday, March 26, 2013

Nursing In Public: To Cover or Not to Cover

     There is an ongoing debate in the breastfeeding community about covering up while breastfeeding.  Many lactivists insist on nursing without a cover.  Others may even be rude to a nursing mother who is nursing in public.  A cover is a personal choice.  Nursing in public may be more comfortable to you while you are learning to latch on discreetly with a nursing cover.  Once you and your baby learn to latch well, a nursing top or other discreet top may work for you.  If you are in a group of women, it is actually helpful to nurse without a cover so that other women can learn from you.  One of the reasons our culture has a difficult time with the early days of breastfeeding is that we have never seen it done.  Although Spanish is my second language, in my 20 years of counseling nursing mothers I have had less Hispanic clients who needed help with latch due to the culture of women helping women. 
      If you choose to cover, the Bebe au Lait or Hooter Hider is an excellent nursing cover because they have a patented stay to keep the cover lifted out just enough for you and your baby to have eye to eye contact.  The LatchOn Nursing Strap is a great go-to item because it turns any blanket into a nursing cover making it very easy to carry with you even if you are only toting a purse, one diaper and wipe.
   So cover, don't cover.  It is up to you.  Do whatever makes you, not just others feel comfortable.  The more comfortable you are, the longer you will breastfeed!

Introducing a Bottle to the Breastfed Baby

     Waiting to offer a bottle is essential for initation of lactation.  Experts tell us that we should wait at least 3-4 weeks.  I believe it should be at least four weeks because even a bottle of breastmilk can interfere with stimulation during the three week growth spurt period. It can undermine moms confidence when baby gulps a bottle down during the hunger games of growth spurts.  When you offer a bottle of expressed milk, it is essential to pump to replace that feeding or it can interfere with milk supply or cause plugged milk ducts. 
     Most moms begin a bottle because they want the freedom of allowing someone else to feed or out of necessity because they are going back to work.  If you choose to nap and let Dad feed make sure to fully empty the breasts by nursing first.  If a bottle has been given while you were asleep or running errands, pump when you return even if you have nursed immediately when you came through the door.  Anytime a bottle was given, baby will not be as hungry and therefore not empty the breast as well and residual milk can cause clogs especially in the early weeks of breastfeeding.
     If you are not going back to work or want someone else to feed, a bottle is not an absolute.  You may wait longer if you wish, but some moms who wait longer than 8 weeks find it difficult to coax their baby into taking a bottle.  So if you are going back to work, the best window may be 4-8 weeks.  If you are not going back to work, but find yourself in an emergency situation that you have to be away from your baby, the baby will normally take a bottle from another person if you are gone very long.  If you are not gone more than 3-4 hours, the baby may also wait for you.  In any case, it is important to have stored up at least 24-48 hours worth of breastmilk in the freezer.   Here is a breast milk intake chart to help you determine how much you need based weight.

Store milk in 2-4 oz increments.  This makes it easy to defrost and access just the right amount without waste.  You may store breast milk in sealed bottles or breast milk bags.  Bags have been the preferred method for most moms due to the quicker defrost time and space saving size.  They are more costlly in the long run so bottles may be more cost effective and better for the environment, but today inexpensive biodegradable breast milk storage bags are available.

Sunday, March 24, 2013

Breasfeeding: When and How to Supplement a Breastfed Baby

     Although breastfeeding is natural and a full milk supply is available in almost all women, there are times that milk supply is down for reasons that we can usually trace to supply and demand issues.  These issues include mother baby separation, scheduling, good baby syndrome, and birth control prescriptions. 
     Many times, however supplementation occurs because of perceived low milk supply.  Just because a baby gulps down a bottle of formula when offered doesn't mean moms milk supply is low.  If you feel your milk supply is low, stop and calculate.  First, check your baby's wet and dirty diapers.  Your baby should have at least 8 diapers.  The number of dirty diapers is age dependent.  If your baby is 6 days to six weeks, he should be having 3-4 silver dollar sized stools per day or more.  If your baby is over six weeks as little as one stool every 3-5 days can be normal.  Your baby's stool schedule changes at about six weeks so if additional changes occur, check weight.
     If your baby is not wetting an pooping properly, the next step is a weight check.  Your baby at ages 6 days to 6 months, should be gaining an average of 3/4 oz per day.  You can go by your doctor's office and use their scale or buy a baby scale or rent a baby scale.  Calculate how many weeks it has been since the last weight check and subtract from the new weight.  Divide the difference by the number of weeks.  Your baby should have gained at least 5 oz per week.  (Remember, there are 16 oz per lb.)
     If your baby has really not gained appropriately and you must supplement, do it wisely.  If your baby is under six weeks, use a 10 cc slip tip syringe for finger feeding, medicine cup or feeding tube.  If using a syringe, please note that 30cc is equal to one ounce.  Feeding tubes can be used for finger feeding or for supplementing while at the breast.  If you have an older baby, someone other than mom may supplement with a wide-mouth slow flow silicone nipple in a tummy to tummy position with the baby held tightly.

     Before you begin supplementing, check your milk supply.  Do this with a professional grade or hospital grade double breast pump.  The best time of day to check milk supply is the second feeding of the morning.  Nurse during the first feeding as usual, wait three hours and then double pump for 15 minutes.   Use the breast milk supply chart on this page to determine if your milk supply is normal.        
     Once you determine your output, subtract that amount from the average output and supplement only that amount.  For example, and 8 lb baby extracts an average of 2.5 ounces per feeding.   If your output is 1.5 ounces, then supplement no more than 1 ounce after feeding for no more than two days.  Pump after each and every feeding that you supplement.  Use breast milk to supplement whenever possible.  On the third day, check your supply again.  If your supply is now 2 ounces, only supplement the difference of 1/2 ounce and check again on the third day.  This consistent stimulation of pumping and limited supplemental schedule should keep the supplementation from spiraling into a vicious cycle. 
     Do not supplement additional amounts unless your baby has signs of dehydration such as no wet diapers or diapers that have a red brick powder-like substance in them.  If your baby is fussy after the allotted amount, put them back to the breast.  This will help you baby stimulate breast milk production as well as soothe them with suckling.
     Call a doctor or lactation consultant if your supply does not increase with the above method.  You can use lactation bars or cookies than contain galactagogues or take herbs like Fenugreek and Blessed Thistle to increase milk supply.  You can take 3-5 capsules of Fenugreek three times daily or a combination of three Fenugreek and two Blessed Thistle capsules three times daily for a minimum total of 15 capsules per day.  In general, herbs in glass bottles are more potent than those in plastic bottles due to freshness and quality.
     Is summary, supplementation should not be taken lightly.  If done improperly, it can be the beginning of the end of breastfeeding.  If necessary supplement wisely, minimally and with a plan for increasing milk supply in hand.


Tuesday, March 5, 2013

Breastmilk: The Perfect Food

Breastmilk varies in composition from colostum to transitional milk to mature milk and each stage is perfect for your baby's stage of development. 

Colostrum can begin leaking during the last trimester of pregnancy and is produced during the first few days (1-7 days) after birth.  It contains a higher amount of protein and less fat than transitional or mature milk. It is thick and sticky and coats and protects the infant's stomach.  It is high in antibodies and acts as the first immunization for your baby. Colostrum has a laxative effect on the newborn, helping your baby pass the meconium stool.  It also comes in teaspoons and not ounces, making it the perfect amount for a newborn whose stomach is the size of a walnut.

Transitional milk is the breast milk that transitions from colostrum to mature milk.  Transitional milk is produced from approximately day 8 through the second or third week in most women.  However, when moms deliver a baby prematurely, transitional milk can last much longer as it is the perfect milk to help the baby grow in that stage of development.  Transitional milk includes high levels of fat, lactose, water-soluble vitamins, and contains more calories than colostrum.

Mature milk is usually present at about 21 days after birth and going forward. It can vary in fat content, as the fat of the milk received by the infant increases as the feed progresses.  This progression is also called hindmilk.  Mature human breast milk is 80% water and contains whey proteins, carbohydrates, fats, minerals, vitamins, enzymes, hormones, anti-infective and anti-allergenic agents. These enzymes, hormones, anti-infective and anti-allergenic agents cannot be reproduced in an artificial milk. Human milk has a combination of amino acids that is unique to human milk. The type of protein and the finely balanced combination of different amino acids such as glutamic acid and taurine enable the baby to digest and absorb fats in their intestines in the first few weeks of life. The combination of ingredients in breast milk actually changes and matures as the baby grows older, to specifically suit your baby's changing needs. 

Each stage of breasmilk is perfectly formulated for your baby's needs as they grow and develop,  You are enough for your baby.  It is the main source of nutrition thoughout the first year.  After six months when your baby is stitting completely alone, if you wish to being solid foods, know that this is a complement to breastmilk and not to take the place of their superior food.  Nurse first and give a small amount of solids immediately afterward.  This way your baby doesn't fill up on anything other than breastmilk.

Saturday, March 2, 2013

Sleep Training and Breastfeeding

     Sleep training is understandably a popular subject among sleep deprived new mothers.  Unfortunately popular methods like BabyWise and the Ferber method can decrease milk supply dramatically.  I recently had a mother contact me who was using the Ferber method.  Her 5 month old baby who was previously gaining weight well had only gained 3 ounces in six weeks after starting the Ferber method*.  This can occur because a baby is not feeding frequently enough during the day and then is not being fed when he wakes in the night.  Please know that sleep should take a back seat to weight gain.  And waking at night is not only healthy for milk supply, but there may be other benefits as well.  Breastfed babies have a lower incident of SIDS.  We do not know whether that is due to the superior nutrition in breast milk or whether it is because they wake more frequently at night.  Breast milk is more easily digested than formula so it is normal for the breastfed baby to feed more frequently than a formula fed baby. 
     Having stated the case for night nursing, I do not want for you to loose all hope that you will ever sleep all night again.  Here are some things you can do to gently guide your baby into a longer nights sleep:
1.  Make sure that your baby feeds frequently during the day.  A baby under 6 months of age should feed at least 8 times per 24 hour period.  The baby 6-12 months normally feeds 5 times per day.  Getting more feeding in during the daytime hours, will help with less feedings at night.
2.  Unless you want to practice attachment parenting and the family bed, you can start with the baby in his or her crib at the beginning of the night.  If after nursing the baby at bedtime, you put the baby in a crib, when he learns to sleep through the night, he is already in his own bed.  This prevents the baby from waking just because he smells your milk.  (Note:  If your baby is not gaining weight properly or you are trying to increase milk supply, you should certainly take the baby to bed with you for unlimited feeding.)
3.  Try to keep your baby on task when feeding during the day.  If your baby is distracted, try nursing in a quiet darkened room or use distractions for the older children to be less of a distraction for your baby.  One of my favorite tricks is to devide toys into bins and bring down a fresh bin of toys right before nursing.  Another is to have a drink or helthy snack ready for your toddler so his needs are met before you start.

Additional Tips for Moms:
1.  Don't let sleep training "experts" fool you.  It is not normal or even healthy if you look at the SIDS studies for a baby to be alone in his crib for 12 hours.  Count it a blessing if your baby sleeps for 5 hours so you can get some REM sleep and jump for joy if he sleeps for eight hours at any given point in time.  This is the norm for breastfed babies. 
2.  Sleep when your baby sleeps.  It may be necessary for you to get a nap during the day or even go to bed a little earlier if your baby goes to sleep early for you to get your much needed sleep.
3.  Know that normal "schedules" go out the window when your baby goes through growth spurts.  Even if your baby was sleeping for 5-8 hours, during the 3 week, 6 week, 3 month or 6 month growth spurts, feeding will be more frequent.  This is normal and usually only lasts 5 days if you do not delay the feedings.

     Breast milk supply is all about supply and demand.  Weight gain is based on total calories consumed in a 24 hour period.  If your baby is distracted during the day and not feeding well, it is important that he or she gets her calories at night.   You are a good mother, if you were not you would not be reading articles to learn more about parenting your baby.  Every child is different and norms do not hold true with every child.  All I can do is give you information based on training as an International Board Certified Lactation Consultant and 20 years of experience.  I hope this article helps you to protect your milk supply and meet your breastfeeding goals.

*Note:  The average baby from 6 days to 6 months of age gains 5-7 ounces per week.