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Let's talk about Triple Feeding. Triple feeding is when a Lactating parent breastfeeds, pumps and bottle-feeds at every feeding. Does that sound exhausting? It is! It is necessary sometimes but it is something I recommend only when truly needed. There are very important points to keep in mind if you are on this care path. First let's review some reasons why this may have been recommended.
1. Excessive newborn weight loss 2. Jaundice 3. Sleepy at breast 4. Late pre-term challenges (babies born between 34-37 weeks) 5. Ineffective suck pattern at breast 6. Difficulty latching (This list is not exhaustive) The first important point is timing: Newborns eat every 1-3 hours so Triple Feeding often can feel like parents have no break at all. I recommend keeping the whole cycle or process of the feeding to 40 minutes or less. This means, breastfeeding, pumping and bottle-feeding all in 40 minutes. This becomes a challenge when the baby is actually improving and nursing better and longer. In this scenario, we don't limit their time on the breast. But if your baby is simply asleep despite adequate waking techniques, trying to wake them for an hour is counterproductive. Give the nursing a good attempt but if its been 10 minutes, and your baby is still not latching well, you can move on to the bottle portion of the feeding. There will be many times to breastfeed in the future. Luckily babies reflexes to suck and find the breast are present for months. The second point concerns duration: This is a Short Term Care Plan! I educate my clients that they can proceed with Triple feeding for 48-72 hours. At that point, a re-evaluation by your (IBCLC) Lactation Consultant is necessary. The goal of Triple Feeding is to build and maintain your milk supply while addressing your baby's latch issues and keeping the baby fed and energized to learn to nurse. Milk supply will increase over 3 days with adequate stimulation and the baby has also potentially changed in that time. A Lactation Consultant (IBCLC) can re-assess your individual situation and recommend a more sustainable long term plan based on your needs. It is not wrong to continue this method for longer than 3 days. But it is a lot of work. Working with a knowledgeable IBCLC who can support you throughout this process is essential. Triple feeding has a place in reaching lactation goals but it can also be discouraging as it is a lot of work. Enlisting partners to complete the bottle portion of the feeding is helpful. Family members can also clean pump parts and prepare bottles. Reaching out for help and support is necessary!
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This is the number one question I field every day. We can't measure what comes out of our breasts. We can't feel how much is going into our babies during a feeding. Our breasts go through so many changes and one's breasts can feel full, filling, engorged and soft. In all these cases, your baby can be taking in plenty of milk. So how is a new parent to know if the baby is receiving enough milk?
Luckily there are measurable, objective methods to determine if your baby is eating enough and growing adequately. 1. What goes in, must come out! A baby 7 days old and older should have a minimum of 6 wet diapers every 24 hours and 3-4 stools every 24 hours. In the first week after birth these numbers are smaller and should be carefully tracked. They are as follows: Day 1: 1 urine, 1 stool Day 2: 2 urine, 2 stools Day 3: 3 urine, 2 stools Day 4: 4 urine, 3 stools Day 5: 5 urine, 3 stools Day 6: 6 urine, 4 stools Day 7: 6 + urine, 4+ stools If your baby has less than the numbers above, you must call your Pediatrician. If your baby has more than these numbers, that is great! It is normal to see 8-10 diapers every 24 hours by day 7 of life. Usually by day 4 or 5 the stool also will change to a yellow color and become 'seedy' in consistency. 2. The baby's weight over time will tell you how the baby is doing while breastfeeding. Baby's can lose up to 7% of their birth weight in the first week of life. They should get back to their birth weight by day 7-10 days post birth. They usually will then gain 1/2 to 1oz a day after that in the first month of life. Pumping is not an accurate method to evaluate how much your baby is taking from the breast.The baby, in general, will remove twice as much milk from the breast as even the best double electric pump can remove. Pumping is very different from breastfeeding. It is mechanical. Some women don't respond very well to a pump or may be using a pump that is not ideal for their breast. The size of the flanges and the suction power and cycles also effect milk removal amounts. Pumping is a great addition while breastfeeding in many circumstances but it is not a measure of how much your baby is transferring from your breast. 3. An additional method to evaluate your baby's intake is a direct measure during a feeding. A weight is done prior to nursing and then retaken after the feeding. The difference will be the amount your baby took from your breast. For example, if your baby weighed 3000 gm before the feeding, and then weighed 3045 gm afterwards, we can deduce that your baby took in 45 ml or 1 1/2 oz of breast milk during that particular feeding. Some people will want to have this evaluation done to make sure breastfeeding is going well or if they are experiencing any difficulties. An International Board Certified Lactation Consultant (IBCLC) will include this in their evaluation and observe a full feeding to develop a working care plan for you and your baby. 4. Observing your baby can also tell you if they are satisfied after a feeding. In the first few weeks of life, many babies are very sleepy in general and the following items are not reliable. When babies start a feeding, often their hands are clenched in fist. When they are full, their hands relax and their fists open up. Their body is very relaxed and they may sleep. If your baby continues to cry and display hunger cues after a long feeding especially more than once, you should seek help from your Pediatrician and an IBCLC. I hope this blog will give you more confidence in breastfeeding. These are general educational guidelines. They are not to be taken as medical advice. Please reach out to a Doctor if you have any concerns about your baby's intake. Today is World Breast Pumping Day, a day we celebrate all the women working so hard to provide that precious breast milk for their babies. Breast milk is so important for the health of babies. There is a myriad of reasons to pump. Personal choice, difficulty latching, prematurity, going back to work, and donating breast milk are just some that come to mind.
Pumping is a difficult undertaking. Our bodies sometimes don’t respond as easily to a mechanical pump as they do to a nursing baby. Finding the right pump and correct flange sizes is important. There is constant cleaning of pump parts. There is the warming of the breast milk. Finding the time and place to pump especially at work can be a continuing challenge. Sometimes women who pump can be more at risk for struggles with plugged ducts and mastitis. But they carry on providing that liquid gold for their babies. Today we celebrate them. One day I met a mother who was pumping a more than adequate amount of milk for her baby. She had struggled with latch issues and felt defeated. She said to me, “I’m disappointed that I couldn’t breastfeed”. I said, “But you Are breastfeeding. Providing breast milk is breastfeeding.” She was so happy and said she never looked at it that way. I did and do recognize her sense of loss over a direct breastfeeding experience. But I also wanted to celebrate her awesome victory. Pumping is Not easy. Breastfeeding is not easy. Today we celebrate World Breast Pumping Day. Those babies love that milk! As a Lactation Consultant I get inundated with questions about pumping. Everyone I speak to has questions about when and how to pump. I want share some basics on using a breast pump. Let's talk about efficient milk removal. The best method to remove milk is an effectively breastfeeding baby. They can remove twice the amount of milk that an electric pump can! This reminds us that what we can pump is not necessarily the same as what the baby gets. The next best method is Hand Expression. Compressing the ducts between our fingers is very effective. Then there are hand pumps and multiple types of electric pumps. An electric pump is not so good at removing that thick milk (Colostrum) in the first few days. Do not be discouraged. You will see results usually starting by day four post delivery. The most powerful pumps are the multi-user pumps that are often available for rent at hospitals and pharmacies. These pumps cannot transfer any infection between users. One model is the Medela Symphony. This pump is recommended in the first month after delivery in certain circumstances: history of low milk supply or significant risk factors for low supply, separation from the baby (baby is in the Neonatal Intensive Care Unit), twin delivery, and a baby who is not nursing effectively. (This list is not exhaustive). This type of pump has a more powerful motor and is intended to help initiate a milk supply. Commercially available pumps are intended to maintain a supply that is already established. The list of these pumps is long. Some examples include the Spectra, Medela pump in style, Ameda, etc. Your insurance company has to provide you with a new double electric breast pump with every pregnancy. These type of pumps are not rated as multi-user in general and should not be shared. There is a chance of infection between users. Also their motor is designed to last through regular use for approximately a year. It is possible that using it a few years later with a new baby will not produce the same results. The motor can be worn out. This is why insurance provides a new pump with each baby! On to the actual pumping! Pumping is hard! Let's be honest. It's not fun. It's mechanical and sometimes our bodies don't respond the same way to a pump as they do to our adorable baby. The let down is partially psychological. Some techniques that can help are: looking at a video/pictures of your baby while you pump, smelling clothing that your baby was wearing, covering the collection bottles with a blanket, and distracting yourself with a fun activity (chatting on phone, TV, social media). Don't watch the milk drop into the bottle! Remember that sometimes trying a different brand pump can make a big difference for some women. If you are having a challenge with your milk supply, a consult with a Lactation Consultant is the best way to get back on track. The size of the flanges or cups that go on your breasts is very important. If they are too small or too big, this can negatively impact milk supply and cause pain and damage to your nipples and/or breasts. It is also important that pumping never hurt. Do not turn the suction pressure up higher to attempt to get more milk. Pain inhibits the letdown! The amount and times to pump vary significantly depending on your individual situation. Remember to wash your pump parts every time with soap and water. Sanitizing the parts once every 24 hours in the first 2 months of the your baby's life is also recommended. This can be accomplished with your dishwasher, microwave steam bags or a quick boil. Storage guidelines for breast milk: www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm (In addition, if your baby is premature or has health challenges, it is recommended to refrigerate your milk directly after pumping) There are many different ways and reasons to use a breast pump. Your Lactation Consultant can advise you on the best course of action for your particular situation. You can be successful pumping with the right knowledge! There is an emerging and recently increasing trend of placenta encapsulation and consumption. I want to spend some time speaking to you about this very important health topic. Placenta encapsulation is the practice of consuming the placenta after it has been steamed, dehydrated, and placed into pills. This practice has been touted to produce health benefits. As a Lactation Consultant, I encounter questions about the benefits and safety of this practice. As with many medicines and treatments, more research is needed. At present, the research has not shown any benefit to consuming the placenta. In fact, there is growing evidence that it can cause harm. In the Lactation Community around the country, we have noticed an alarming trend of lowered milk supply, delayed onset of lactation and subsequent weight loss in the infants and failure to thrive. There are some residual hormones left in the placenta product that is consumed. These hormones may be responsible for inhibiting milk supply. A complete detachment of the placenta after birth is necessary to initiate a full supply of breast milk. Adding these hormones back into the body can be detrimental. "Taking placenta back in after birth inhibits prolactin from binding and producing milk. Some women’s milk supply may be able to withstand this hormonal suppression, but many don’t. This is like having retained placenta or taking hormonal birth control pills, which can lower milk supply" (8,9,12,13,14,15) In addition, there is the possibility of infection. There was a case of an infant developing Group Beta Hemolytic Streptococcus (GBS) due to the mother having ingested her encapsulated placenta. The CDC found the source of the infection was the placenta pills. (Buser, 2017). The current guidelines in clinical Lactation are to discontinue consuming placenta in the presence of a low milk supply. This is due to the high likelihood that it's consumption is the cause of the decreased or delayed milk. Fortunately, most women develop or regain a full milk supply after cessation of placental ingestion. I feel strongly about this issue. A thorough education on the topic for expectant and new parents is essential. Until a through body of research on Placenta Encapsulation has been conducted and proven its benefits and safety, the practice should be discouraged. References: Davis, E. 2012. Heart and Hands: A Midwife’s Guide to Pregnancy and Birth (5th edition) Berkeley, CA: Ten Speed Press. (pp 199-219) Sinclair, C. 2004. A Midwife’s Handbook. St.Luis, MO: Saunders. (pp 506-507) Neville MC, Morton J, Umemura S. Lactogenesis. The transition from pregnancy to lactation. Pediatric Clin North Am. 2001;48:35-52 Walker, M. (2017). Breastfeeding management for the clinician: Using the evidence (4th edition) Sudbury, MA: Jones and Bartlett. (pp 118 - 127) Riordin, J.(2005).Breastfeeding and Human Lactation.(3rd edition)Sudbury,MA:Jones and Bartlett(pp 73-77) ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015. http:/www.bfmed.orgMediaFilesProtocolsContraception%20During%20Breastfeeding.pdf Buser GL, Mató S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the Field: Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta — Oregon, 2016. MMWR Morb Mortal Wkly Rep 2017;66:677–678. DOI: http://dx.doi.org/10.15585/mmwr.mm6625a4 Tongue Tie is a complicated and confusing topic. I have been hesitant to write about it. But as a Breastfeeding Advocate I feel like the time has finally arrived to attempt to shed some light on this issue. "Tongue-tie is the non-medical term for a relatively common physical condition that limits the use of the tongue, ankyloglossia." "In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems." "Nursing mothers who experience significant pain while nursing or whose baby has trouble latching on should have their child evaluated for tongue tie. Although it is often overlooked, tongue tie can be an underlying cause of feeding problems that not only affect a child's weight gain, but lead many mothers to abandon breast feeding altogether." (American Academy of Otolaryngology-Head and Neck Surgery) Like other medical variations, there is a range of severe to more mild tongue ties. What is very important is how the tongue is functioning. The appearance is less important. Sometimes the impact or even the presence of a Tongue Tie is not realized until weeks after birth. Here are some symptoms or signs that your baby may have a restriction that is affecting your nursing relationship.
Lactation Consultants and Registered Nurses do not diagnose Ankyloglossia. We are trained to recognize it and assess it's potential impact on your baby and you and your milk supply. We are uniquely positioned to take the time to observe a full feeding and take an all important breastfeeding history. We can help refer to experienced Medical Providers to evaluate, diagnose and treat Tongue Tie. It is also very important to combine release with effective myofunctional therapy to allow any release to reach it's effective full potential. A follow up with a Lactation Consultant can help ensure a smooth transition post release. References: Copyright 2018. http://www.entnet.org/content/tongue-tie-ankyloglossia. American Academy of Otolaryngology-Head and Neck Surgery. 1650 Diagonal Road, Alexandria, VA, 22314. 1-703-836-4444. Retrieved on 5/19/2018. I help many families learn to breastfeed in the initial two weeks after birth. One theme that has emerged for many women and their partners is an expectation of perfection early on in the process. Mothers may report having some good feedings and then some difficult feeds. They express being discouraged by this. Many women feel as if they are failing their newborns. Some parents even will feel the need to supplement with formula in the first 24hr of life due to some difficult feedings. I like to think of learning to breastfeed as learning a new skill. It is not unlike learning to ride a bike. In the first week while a child is learning to ride a bike, they will fall and skin their knees a few times. There will be lots of hand holding and some stress. We don't expect our child to ride perfectly the first time they get on the bicycle. Babies have just arrived in the world for the first time. There will be imperfect attempts at nursing. This is normal. Also a well baby who is born at term can tolerate some imperfect feeds in the 24hr of life. The main concern that I have as a helping professional is the stress that mothers put on themselves to be perfect at breastfeeding immediately after the baby is born! I want to allay their fears and encourage the new mother to enjoy this time with their newborn. Let's see it as learning a new skill in the first few weeks.
There are many reasons why it may be necessary or desirable to combine nursing and bottle-feeding. The bottle may contain formula or breast milk. In the first three weeks this combination poses unique challenges but is very feasible if done with direction and care. If the baby is receiving additional supplementation after nursing or instead of an at-breast feeding, the milk supply may decrease if pumping is not initiated at the same time. It is therefore recommended that a woman pump her breasts any time the baby receives a supplement, even if she has recently breast fed. This holds true in the first three weeks after delivery to ensure an adequate milk supply. The recommendations change later on. Many women will report that they had a low milk supply with their first child. During our conversation, they relate that the they needed to supplement their first baby for some reason and they did not pump or did not pump enough. This is a very common reason to have a decreased milk supply. This person will most likely go on to produce an adequate supply with their subsequent children as long as they follow the pumping regimen if needed. These suggestions can be very overwhelming especially early on when parents are already exhausted. I always stress that the pumping is short term. When an adequate milk supply is apparent, pumping may be gradually lessened. Many parents are faced with a medical recommendation to supplement their baby and this can cause concern about a disruption in the breastfeeding experience. It is possible to preserve the breastfeeding relationship in these circumstances.
There is a common theme when I speak to women who are having some issues initiating a breastfeeding relationship. Many women who have slight difficulty with the latch will report the same experiences. They state that sometimes they allow the baby to nurse with an incorrect or shallow latch because "at least the baby is nursing" or because "the baby was so hungry" or "at least the baby is getting something".
These are counterproductive and concerning assumptions but they are also a natural response to the demanding and tiring experience of nursing a newborn. Why is a deep and correct latch so important? When the baby is latched correctly they are able to compress the milk ducts in the breast and remove the appropriate amount of milk. This will lead to proper weight gain and growth and development. A shallow latch leads to decreased milk intake. This can lead to improper weight gain. Another issue that is important in considering latch is milk production. The milk is produced by the milk being properly removed by the baby. If a mother has a repeatedly shallow or incorrect latch, her milk supply will decrease and could become compromised. An additional very important issue to consider when speaking about a shallow latch is nipple damage. Incorrect latch can lead to blisters, cracks, fissures, bruises, bleeding and scabbing. This can put the woman at risk for infection of the nipple and of the breast itself. Damage to the nipple also is very painful due to the large amount of nerves in the nipple tissue. This can directly lead to cessation of breastfeeding due to nipple pain. If you are aware that your baby is not attaining a correct and deep latch it is recommended that you ask for help. Also you can maintain your milk supply by pumping your breasts while looking for assistance. The baby is learning a new skill and so are you! I have realized over time that Breastfeeding does not come naturally to many women. I do practice in the Northeast in a heavily populated area. The make up of our culture has implications for breastfeeding. The majority of my clients have never seen a woman breastfeed. Many women have not even had exposure to a newborn. Simply holding a small baby is a daunting first task that must be learned in order to successfully nurse. Other cultures in my area are very different in contrast.They likely have grown up around many young women in their family who have been breastfeeding. They have observed the techniques and normalcy of nursing and may have more experience handling newborns. These women have an advantage and often have less difficulty learning to nurse. We can overcome this lack of exposure with adequate support, teaching and practice. This does not delay the initiation of breastfeeding. I do observe that this issue can cause some additional anxiety around having a newborn and learning to hold and feed the baby. As a Lactation Consultant and a Registered Nurse, one of my goals is to empower women and their partners to feel more comfortable with their baby and become independent with feeding and care.
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