Breastfeeding Part 3 – Pumping

Whether you plan on staying home with your infant or going back to work, most breastfeeding mothers end up pumping at some point during their breastfeeding journey. Pumps range from single, manual pumps to double electric ones. For mothers who are only going to pump a few times, a single, manual or electric pump will work. However, if you plan on working out of the home or pumping frequently, investing in a double electric pump will increase your success rate and decrease your frustration in the long run. You do not have to buy a pump, you can borrow one from a friend, buy a used one or rent one from your local hospital. Several medical insurance plans are now covering the cost of pumps – all you have to do is call the number on the back of your insurance card and ask about your breast pump benefits (you may need a prescription from your pediatrician or OB/GYN). Just make sure to get new tubing, nipple shields, and collection bottles when you start pumping, especially with a used pump.

The process of electric pumping can be daunting at first, ask a lactation consultant or nurse in the hospital to show you how to set it up and get started. First, hand off your infant because it is very difficult to pump holding your baby! Next, connect the tubing, set up the nipple shield and collection bottles. Finally, place the nipple shields to your breasts and turn on the suction, slowly. If you are going to be double pumping frequently, several manufacturers make hands-free pumps and bras for easier use. Pumping takes an average time of 10-20 minutes per breast. Continue to pump until the milk flow stops if you have adequate supply, or longer (5-10 minutes) if you are trying to build up your supply.

Some breastfeeding mothers start pumping in the hospital, within a few days of birth. Breastmilk supply is based on demand – so the more stimulation to the breast, the faster milk “comes in”, with increased supply. Sometimes, mothers pump because they want their milk to come in faster, which works, but is not necessary for most mothers. The mothers who do need to pump are the ones with infants who are being supplemented formula because of jaundice or weight loss, or those who have infants in the NICU.

There are several different strategies for pumping and you will hear different advice from everyone you ask. I make my recommendations based on whether or not you are going back to work and when. For mothers who are going back to work within 6-8 weeks, I recommend starting to pump during the “engorgement phase” – usually between days 3-7 after birth. You will make plenty of milk during that time and it will help make you feel more comfortable. Pump only a couple of times per day, after your infant feeds. Remember that when you pump after your baby feeds, your body will make more milk at that time… so you can take advantage of that and pick times when you will be able to pump when you go back to work. Continue to pump daily after that to store milk for when you go back to work. For mothers who are not working outside the home or have an extended maternity leave, I recommend starting to pump and introducing a bottle a couple of weeks before you need it or just doing it “as needed” for a night out.

Expressed breastmilk can be stored in hard plastic bottles or breastmilk bags. I recommend storing or freezing in 2-4 oz allotments, so you do not waste any milk when you thaw it for your baby. As your infant gets older and eats more, 4-6 oz bags work well.  Click here for a chart on safe breastmilk storage:

http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm

While most breastfeeding mothers will admit that pumping is not the most exciting activity, it does give many mothers the opportunity to provide breastmilk for their infants whether they are working outside of the home or just out for a quiet dinner.

Heather Joyce, MD

Breastfeeding Part 2 – The First Days Home

Congratulations…you gave birth, decided to breastfeed, and made it through your hospital stay!  With the support of doctors, nurses, and lactation consultants, by the time you are discharged, hopefully, you are feeling pretty comfortable with the breastfeeding process.

This is exactly how I felt with my first son…so, when I got home and started having difficulty and pain, I felt frustrated and started doubting my ability to breastfeed. He was fussy and frantic at the breast, which lead to painful feeding sessions. I knew some pain was normal, so at the time I didn’t even know I needed help. Most parents would agree that the first couple of nights home with your first infant are the longest, most exhausting nights of your life. Add in difficulty with breastfeeding, and a time that should be filled with joy, becomes one that is filled with frustration. The good news is that this time passes quickly and with some patience and support, breastfeeding can get easier every day!

In my opinion, the biggest reason that new mothers are in this situation, is the fault of our current medical system. We send mothers and their infants home within 48 hours of delivery – well before most mother’s milk “comes in.”  So, many infants start to get very hungry within 24 hours of going home. This is a time when they start to gain back the weight that they lost after birth. If your milk is not “in” yet, then you are dealing with either a sleepy baby who does not have the energy to feed or a frantic, fussy baby.

The second problem that many mother’s run into is engorgement. Once the milk “comes in,” the breasts become hard, swollen and painful. A baby who was latching on perfectly before engorgement, can develop difficulty finding a comfortable latch – especially at the beginning of a breastfeeding session, when your nipple can lay flat against your areola.

Here are my tips to help you get through the fist days of breastfeeding, with as little difficulty as possible:

  1. Find support – a friend, relative, or lactation consultant
  2. Put your infant to the breast as often as they want (every 1-3 hours) – you can work on a feeding schedule later. In the first couple of weeks, the more your infant feeds, the faster your milk will “come in” and the more milk you will produce
  3. If your infant is too sleepy to feed or falls asleep at the breast, attempt to breastfeed for 10 minutes on each side, then pump to let your body know that you need more milk. If your infant is not gaining weight or having problems with jaundice, feed the baby this pumped milk (either with a supplementing tube/syringe or a bottle) after attempting to breastfeed. As a side note, this is exhausting – so utilize your partner or a relative to hold or feed the baby in between breastfeeding/pumping sessions. 
  4. If you are having pain or difficulty latching your infant due to engorgement, express breastmilk either with your hand or with a pump for about 1 minute prior to attempting to breastfeed. Be advised not to pump too much during this time (like after every feed) because you will overproduce milk and this can lead to lots of discomfort.

You will know that your infant is getting enough milk by the number of wet and dirty diapers they are having. They should increase every day until day 5 or 6. They will also start gaining weight around this time. So follow-up with your pediatrician is important.

It is normal to feel nipple discomfort for the fist 1-2 weeks of breastfeeding, though if the pain is making breastfeeding a dreaded task or you develop red sores, cracks or blisters – then find a lactation consultant to help work on your infant’s latch. You will also feel pain and fullness during engorgement – starting days 3-4 and resolving slowly over about a week. This pain should be tolerable with a supportive bra and cold packs.

Within 10-14 days, breastfeeding should become comfortable for both you and your infant. If it is not, or your infant is not gaining weight – seek help, because there are fixes for most breastfeeding problems. However, you need to know that some infants are not great breastfeeders and some moms don’t make enough milk – which makes me very thankful that formula was invented!

Heather Joyce, MD

Breastfeeding – Is it Safe to Exercise?

So … you’ve decided to breastfeed.  You also want to get back in shape following your baby.  While breastfeeding is a huge topic of conversation, there’s not as much talk about breastfeeding and exercise.   Here’s a few questions you may be asking …

Will baby refuse the breast after exercise?  You may have heard that babies don’t accept breast milk as readily after mom has exercised because of a buildup of lactic acid.  However, most studies have found no difference in acceptance of the breast, even after maximum intensity exercise.  Research has also not shown a noticeable increase in lactic acid buildup after moderate exercise.  Even with maximum intensity exercise where there is a minimal increase in lactic acid in breast milk, there are no harmful effects for the baby.  While there may be a change in taste of breast milk from lactic acid, babies will not subsequently refuse to breastfeed because of it.  More plausible reasons for why your baby may refuse to breastfeed after you exercise are issues such as the salty taste of sweat on your breast post-workout.

Is the composition of antibodies of breast milk affected by exercise?  Exhaustive exercise does cause IgA levels (a type of antibody) to decrease for a short amount of time.  However, these levels return to normal within an hour – a decrease in IgA levels in one feeding per day is not likely to be significant.  Moreover, moderate exercise does not affect antibody levels.

Is your milk supply affected?  In short, no.  In fact, some studies have shown that women who exercise regularly had a slight increase in milk supply.  However, if you exercise to the point of exhaustion, or train for an event such as an Ironman, your body may be depleted to the point where producing milk is its last priority.  Bottom line – moderate, regular exercise should not affect your milk supply.

What types of exercise are best?  There really is no “best” type of exercise for breastfeeding moms.  It’s really more about what you enjoy and what makes you feel good.  Because breastfeeding moms are a bit more top heavy, things like running may be more uncomfortable, but it can still be done with the right type of support/attire.

What attire provides the most support for breastfeeding moms?  The key to being comfortable while exercising is finding a good supportive bra that fits you.  I would suggest getting measured at a sports specialty store for women (e.g. Athleta, Title Nine, etc) so that you know exactly what you need.  It really does make a huge difference.  You can avoid the two sports bra routine if you find the right bra that fits you 🙂

Other tips …  Definitely try to breastfeed right before a session of exercise.  Clearly, this is more comfortable, especially for weight bearing activity like running.  You may develop plugged ducts if you  lift weights involving repetitive upper arm strengthening (if that happens, start with lower weight/reps).  And make sure you drink and stay well hydrated!!

Rachel Brewer, MD

Breastfeeding Part 1 – The Initiation

The best time to start breastfeeding is within the first hour after delivery. After an uncomplicated vaginal delivery, most infants are awake and alert for about an hour and will latch and start to suck right away. Not all infants are able to go to the breast immediately and it is OK to wait until you and your infant are ready. Some have problems with blood sugar after birth and need a small amount of formula or sugar water to keep them safe – this is common practice in most hospitals. These infants will not have the energy to breastfeed if they do not get their blood sugar into the normal range. If your infant requires supplementation in the hospital, I recommend pumping every time this occurs, even if you don’t produce any milk – this will let your body know that your infant needs more milk and will help your supply.

During the first days of breastfeeding, most mothers produce a small amount (5-10 ml) of colostrum with each feed. You will feel tugging and pulling, but should not feel severe pain. If you do, then your infant’s latch may need to be adjusted. Take advantage of the nurses, doctors and lactation consultants in the hospital – they will have lots of advice and can provide hands-on help. You will also feel uterine cramping with each feed, this the due to hormonal contraction of the uterus – it hurts, but is good for your body. The more often your baby breastfeeds, the more milk you will produce, the more contacted your uterus will become, and the more experienced you and your infant will be prior to going home.

You will not “know” how much milk your infant is getting, but if they are waking to feed every 1-3 hours, having wet diapers and clearing their meconium, they are getting enough. All infants loose weight after delivery, but should start gaining it back after 5-7 days. Your infant should see the pediatrician for a jaundice and weight check within 3 days after discharge from the hospital.

Breastfeeding for the first time will be uncomforable and sometimes stressful for the fist couple of weeks, but it gets easier. If if continues to hurt or your infant is not getting enough milk to gain weight, then find support. Most hospitals, doctors offices, and specialty baby stores have lactation consultants available. You can also talk with an experienced breastfeeding mother, who may have some great tips for you. Just remember, for every person who tells you that breastfeeding was the easiest, most natural part of motherhood…there are 10 others who will give you a different story.

Next up…the first days home and pumping (aka The Milk Machine).

Heather Joyce, MD

Germ-Fest

So, I am going to digress from the usual sports medicine topics that I love, and talk a little about what to do when germs invade your house.  I mean when your kid gets sick, then you get sick, then maybe your husband, and then your kid again.  The whole process may last weeks (and feel like months).  I’m basing this on recent personal experience that included a nasty upper respiratory illness for my daughter, a GI illness and then pneumonia for my husband, and two nasty respiratory viruses for myself separated by a week. This house is ready for spring.

When one household member gets sick with a viral illness, containing it isn’t easy.  If I could have replayed the last month in my house, I might have bought a hazmat suit to stop the spread of germs … it takes a toll when the virus keeps steamrolling your family members (and the dog Daisy even got depressed – her number of walks/runs dropped dramatically).  Here are a few common sense tips to help prevent the spread of germs.  These steps may seem simple, but I know I skimp a lot on these things when I’m rushed.

Wash your own hands.  Don’t get too focused on keeping the germs off of your kids.  If you’re not washing your hands, you could be the one who infects your healthy child or spouse.

Make washing your kids hands routine.  Of course this seems obvious, but it can’t be stressed enough. Nearly 80% of infectious diseases are spread by simple touch!  When you have a sick toddler or baby, germs get in every nook and cranny (literally).  And when your kids can wash their hands themselves, teach them to do it for at least 20 seconds (maybe sing the alphabet song or something similar).  If soap and water aren’t available, use an alcohol based sanitizing gel until it evaporates.

Disinfect, and then do it again.  Wipe off surfaces that sick household members have touched – doors, tables, counters, handrails, etc.  You can even put some plastic toys in the dishwasher and stuffed animals and other toys in the washing machine.  If you’re experiencing a GI illness in your house, be extra careful to disinfect the toilet, floor, and bathroom sink.

Don’t change dirty diapers in the same place for two different children.  Enough said.  This is a great place to exchange germs.

Mealtime.  Don’t share silverware, cups, plates, food, etc.  Germs love these methods of transportation.

Breastfeeding.  Don’t stop breastfeeding if you get sick.  In fact, the antibodies you pass on might help protect your baby from getting sick.  And if your little one is sick and you are nursing, again, just practice good hygiene to avoid transmission to yourself.

Ok, I know these seem simple.  But take them seriously when a family member gets sick.  I know we will next time!

Rachel Brewer, MD

Confessions of a Modern “Crunchy” Mom – Cloth Diapers

Though I work as a pediatrician full time, vaccinate on schedule, and sometimes hit the closest drive-though for a quick meal, I am often called “crunchy” by my co-workers and friends. There are many aspects of “natural ” parenting that feel right to me, including, cloth diapering, breastfeeding (or pumping) for as long as possible, homemade organic baby foods, and baby wearing. As a working parent, my life is an act of compromise, so I am flexible with my “crunchy” side.

The decision to use cloth diapers with our second child was not easy, but after reading many blogs and talking to parents who have used them, we decided it was worth a try. There are many pros to cloth diapering, including reduced cost, diaper rash, disposable diapers sitting in landfills (for who knows how long), plus they are so cute! We make it work by realizing that we don’t have to use them all the time to reap the benefits. We have used several different brands, all with inserts and covers. We use a diaper sprayer on the toilet and we wash them ourselves. However, we don’t take them on vacation or use them during diarrhea illnesses and when my son started daycare, we brought disposables to use there. As he gets closer to potty training, we have less diapers to wash and truthfully, I enjoy using them more!

Cloth diapering tips:

1) Talk to other parents who have used them and people who work at local stores who sell them

2) Choose a style that works with your lifestyle

3) Make a washing schedule – we do ours every 2-3 days (buy enough to make it at least a couple of days)

4) Use newborn diapers until the umbilical cord falls off – I could not find a way to make the diaper fit without irritating the umbilical stump. Please comment below if you have the secret!

5) Buy a diaper sprayer for your toilet

6) Use extra inserts for overnight – we use hemp (they are thin, but absorbent)

7) Bleach, strip, and lay out in the sun to dry once in a while

8) Use essential oil in your dry bag to hide the smell

Once you figure out a routine and get used to washing poop, it really is doable for any parent who would like to give it a try.  Every cloth diaper that is used, means one less disposable diaper sitting in a landfill!

Heather Joyce, MD

Infant Reflux

This post was inspired by a friend who is having a tough time with a fussy newborn, but dedicated to all the parents out there who have ever cared for a baby with reflux, my husband included.

Reflux, colic, gas, milk intolerance, or general demeanor…there are many reasons for an overly fussy baby. Many babies who cry excessively swallow lots of air and always appear to have belly pain or gas, so figuring out the reason for a baby’s fussiness can be challenging. I will focus on infant gastro-esophageal reflux in this post, though many of these suggestions can help a baby with colic. Some babies with reflux are not fussy at all (they just make huge messes with spit-up), while others can have discomfort, poor weight gain and feeding problems. The symptoms of reflux are caused by milk that makes its way back up through a weak muscle at the top of the stomach, into the esophagus, and to the back of the throat or mouth. Infants do not all have the same symptoms, but can have spitting up, frequent hiccups, swallowing or grunting, arching of the back or neck, coughing, wheezing, difficulty feeding or excessive crying. Most infants with reflux act like they are always hungry, this is because they cry and root as a reaction to discomfort – often 1-2 hours after a previous feeding. If your child has been diagnosed with reflux or exhibits these behaviors, there are many techniques you can use to decrease symptoms.

1) Feed sitting upright – with bottle feeding, this is easy; but with breastfeeding you will have to find the most comfortable position for both you and your baby.

2) Burp frequently – with bottle feeding, this means every 1/2-1 oz; with breastfeeding it is still best to burp in between breasts or after 10-15 minutes.

3) If you are bottle feeding, find the right nipple and bottle. Babies who drink too quickly or swallow too much air spit up more. There are many choices and you may have to try several, but I say go with the one that works best for you and your baby.

4) Feed small amounts, frequently. For small infants, this means 1-2 oz every 1-2 hours; bigger infants need 2-4 oz every 2-3 hours and increase gradually. Do not over-feed your baby, this will lead to more discomfort!

5) Keep your baby sitting upright 20-30 minutes after each feed. Easy to say, not so easy to do (especially in the middle of the night or when you are chasing around another child). You do not have to hold your baby, you can use any contraption that works for you – bouncy/vibrator seat, upright swing, head elevating positioner, wedge with a sling, baby carrier/sling, just to name a few.

6) Position your baby to sleep elevated (30-45 degrees). The easiest way to do this is to put a couple of books under the legs at the head of the crib or bassinet. If you are using a co-sleeper or pack and play, a couple of rolled up towels or receiving blankets under the thin mattress works well. They also make special foam wedges for this purpose.

7) Do not lie your baby down flat on their back, especially after feeding. If possible, try to change your baby’s diaper prior to feeding.

After utilizing these techniques, your baby may still spit-up. If they are happy and gaining weight, your next step is to stockpile burp cloths, bibs, and wet wipes. If your baby has extreme fussiness, coughing, wheezing, difficulty feeding or poor weight gain, you need to take them to the pediatrician. They may recommend an elimination diet (for breastfeeding mothers), a formula switch, or medication for your infant. This can be a very stressful time as a parent, so keep in mind that whatever is causing fussiness in your baby will pass with time.

Heather Joyce, MD