Pumping Tips for Stay-at-Home Moms

With my second and third babies, I intended to pump milk and build a freezer stash so that the baby could have a bottle once in a while if my husband and I went out. What I found was there's not much time or motivation to pump when you're with your baby 24/7, since preparing a bottle is more trouble than just putting baby to breast, and when exactly are you supposed to pump when you have to feed your baby every couple of hours?

I actually did manage to fill a few freezer bags with pumped milk with my second, which I ended up donating because we had so few opportunities to actually give the baby a bottle. My husband worked long hours, we didn't have a budget for hiring a babysitter and going out often, and the few times we did go out, the baby wouldn't take the bottle anyway!

With my third, I resolved to pump for donation and, again, so we could leave him with a sitter, and that time I found even less opportunity and motivation to pump and ended up not putting much aside. He did get some bottles of expressed milk as a newborn, but after a few months, he, too, no longer took a bottle.

So, this time, I vowed I would find a way. One of the biggest difficulties many women have with breastfeeding is the feeling of being "tied" to the baby. You can never go out without the baby because you have to feed him. It's frustrating. Pumping and storing milk toward this eventuality can help. I bought myself a Hygeia EnJoye double electric pump, revived my hand expression techniques, and promised myself and my baby that I would find one time a day to pump and that he would get bottles often enough that we could leave him with a sitter and go out.

Now, obviously the situation is different if you work outside the home and are away from your baby on a regular basis. In that case, the baby is receiving bottles almost every day, and you're pumping instead of feeding during the time you're away from baby. That's not to say it's easy! Just different.

Here are tips for pumping/expressing milk when you stay at home with baby!

• Pick a time of day when you're pretty sure you'll be able to take 15 to 20 minutes to express milk on a nearly daily basis. Many women have more luck pumping first thing in the morning, so if that's an option, it may be a good choice. I tend to pump in the afternoon, but that's just easier for me because we're not rushing to get out the door.
• You may not need a fancy electric pump if you're only pumping once a day. Hand expression can be very effective for many women (myself included). You may also want to try a manual pump, which generally run $30 to $50, rather than a pricey electric pump. Check out my video on hand expression (NSFW) if you're not sure how to do it.

• You can start pumping as soon as your baby is born, if you want, but wait to introduce the bottle until breastfeeding is established, usually around 3 to 4 weeks of age.
• Give the baby a bottle at least every other day or so. This is the mistake we made with both baby #2 and baby #3: If you don't keep giving a bottle, the baby will forget how to use it or will simply refuse to take it, preferring your breast (understandably so). Have someone else give a bottle when the opportunity arises. I had my 7-year-old feed the baby one evening while I made dinner, for example. Baby may not take a bottle from mom but might from someone else. I did manage to give him a bottle myself the other night, but it sure felt weird to me!

• If you have trouble producing for the pump, or you have trouble finding a time between feedings to pump, you can try pumping while you nurse. Latch baby on one side and use the pump on the other side simultaneously. I find this to be extremely effective. Your baby will achieve the letdown for you, and you don't have to keep baby waiting to eat while you pump! It's a win-win. It is, admittedly, somewhat awkward, though, and it may take a few tries to get the hang of it. You can also use this method to help your body "learn" to respond to the pump if you're having difficulty getting letdown for the pump alone, and you can use it to help increase your supply if you're having supply problems.

• Massage and do breast compressions while you pump. If you are pumping just one side, or you have a hands-free pumping bra (highly recommended if you're double-pumping), use a free hand to compress and massage the breast while you pump. Find the full ducts and put pressure there to push the milk forward. This can greatly increase the amount you extract. I find using a combination of pumping and hand expression yields the highest volume in the shortest time for me. Milk removal is the trigger for milk production, so the more you remove, the more you'll produce!
• Remember that your supply will adjust to the demand. You can pump extra and have enough to feed your baby, but only if you pump consistently to tell your body you need that extra milk.
• At first, you may find it difficult to express a large volume of milk. Pump as much as you can, then keep pumping for a few minutes after you've "run dry" to let your body know you want it to make more milk. You should find your milk volume increasing if you pump daily. Be sure you are hydrated!

Milk Donation

If you find you are expressing considerably more milk than you need, even after giving a bottle every couple of days, you can use that excess milk to help another baby in need, either by donating through the Human Milk Banking Association of North America (HMBANA), which provides donor milk to babies in the NICU, or through a private milk sharing arrangement. You can find local-to-you mothers in need of donor milk by visiting Eats on Feets, Human Milk 4 Human Babies, or Milkshare.

Private, mother-to-mother milk sharing is controversial and not regulated or endorsed by the FDA, but it is legal and completely up to you and your milk recipient whether you want to enter into such an arrangement. Milk donors typically do not charge recipients for their milk but may ask the recipient to cover costs such as storage bags and shipping (if applicable). Milk donation is totally voluntary. Some recipients may ask that you be screened for diseases that can be transmitted through breast milk (a simple blood test). As a donor, you are doing a great favor to a baby and mother in need, but you also have a responsibility to ensure that your milk is safe for another baby to drink, meaning you should use best practices in expressing and storing your milk to ensure it is not contaminated or soured.

Jaundice, Part I: Baby Boy Turns Yellow

This is the first in a two-part feature on jaundice. In this post, I'll tell you Baby Boy #4's jaundice story, and in the next post I'll address jaundice from a more clinical perspective. Now that Baby Boy has been named, we'll call him Y.

At 5:30 a.m. on Tuesday morning, when Y was about 27 hours old, the nursery did a heel stick to draw blood for his PKU test. This is a standard newborn screening done at approximately 24 hours of age. At the same time, they checked his bilirubin levels to see if he was at risk of needing treatment for jaundice. Most people know jaundice as a yellowing of the eyes and skin due to various problems associated with the liver. In newborns, it's a relatively common condition due to the breakdown of excess red blood cells in the baby's body after birth. Most babies will clear out the bilirubin on their own without needing special interventions, but some babies will have bilirubin levels high enough to elicit concern, as very high levels of bilirubin may cause irreversible brain damage called kernicterus.

But back to Baby Y. When the pediatrician came in to check him over and report on his test results, the first words out of her mouth were, "Did any of your other kids have jaundice?" When I told her all three had, and two had required home phototherapy, she nodded. She showed me his bilirubin level, which was 8.6. For his age, this was considered "high intermediate risk". If the number climbed into the "high risk" zone, he would require treatment. The chart below is the standard risk chart for newborn jaundice. You find the baby's age in hours along the bottom, then plot the bilirubin level on the left and see what curve you fall along. A level of 8.6 in a 28-hour old baby was near the high end of the high intermediate risk zone.

The question then was, do we take a wait-and-see approach, or do we take it on more aggressively, knowing that (a) all three of his brothers had relatively high bilirubin levels, and (b) he was already nearing the high risk zone? Levels usually peak between 4 and 6 days of age and then fall off gradually. To clear out bilirubin, the baby needs to poop, which means the baby needs to eat. Since breastmilk supply doesn't usually increase until day 3, and most babies under 3 or 4 days of age are still clearing out meconium, it takes a few days for the excess bilirubin to be excreted. I was still only producing a small volume of colostrum, and Baby Y wasn't pooping much, so we knew his levels would continue to rise for another day or two, at least. But we didn't know if they'd rise sharply or level off. There's really no way to know what will happen in any given baby.

I had been planning to go home on Tuesday, though I was technically entitled to another night in the hospital if I wanted to stay. The pediatrician suggested that I stay Tuesday night and let Baby Y have jaundice treatment through the night. In this way, we might be able to bring down his bilirubin levels to the low intermediate risk zone and then, even if the levels continued to rise a bit for another day or two, they would likely stay on that low intermediate risk curve. If we didn't treat Tuesday night, we would need to monitor him closely (by taking blood daily to measure his bilirubin levels), and if his numbers rose into the high risk zone, then we would need to treat, which might entail readmission to the hospital for him, meaning I'd have to find a place to stay because I would no longer be an inpatient there.

This put us in a tricky position. On the one hand, I really didn't want to spend another night in the hospital. I wanted to get home to my other three kids, I wanted to come back to life and out of the sickly-feeling, "I'm in the hospital" mode. On the other hand, it seemed the easiest way to ensure that Baby Y's jaundice would be managed with the least amount of hassle. A secondary, but real, consideration was that if his jaundice became severe, his bris would have to be delayed. This had happened with our second baby, and we needed to know if that would be necessary for Baby Y. It seemed that treating him Tuesday night would stave off this potential complication as well.

The pediatrician suggested that we talk it over and that she order another blood test for the afternoon. If the number still placed him on that high intermediate risk curve, or, G-d forbid, was even higher, then that might help us decide for sure whether to stay the night or not. I agreed that this was a good suggestion. So, at 36 hours of age, his blood was taken again, and his bilirubin level was 10.7, still on the high end of the high intermediate range, and likely to continue to rise for at least another day or more. We decided to take the aggressive approach. The goal was to keep him under the "bili lights" for the night, in the hope of getting his bilirubin levels to level off or even drop. If the numbers fell into the low intermediate risk range by morning, then we could feel comfortable going home and not worry so much about having to be readmitted for treatment or taking blood daily to monitor him. A clinical approach, visually examining his color, looking at other symptoms, would be enough to monitor his health, and further testing or treatment would only be required if any other symptoms gave his doctor or me cause for concern. (I will discuss all of these symptoms and risks of jaundice in part II of this article.)

At about 7:00 p.m., Baby Y was whisked off to the NICU to be placed under the bili lights. Basically, bili lights are flourescent, blue lights that break down the bilirubin into a water-soluble form that the baby can then pee out, in addition to the bilirubin being excreted in his bowel movements. It's important to maximize the amount of skin exposed to the lights, so the baby is placed in his bassinet in only a diaper, on top of a pad that shines light up against his back. The bassinet is then placed under a second light that shines down from above him. He wears eye covers to protect his eyes from the bright lights, and he basically just sleeps there. The baby should eat about every three hours but should not be off the lights for more than 30 minutes at a time. The idea is to find a balance between maximizing his time under the lights while still getting milk into him so that he can pee and poop. It's a tricky thing, especially with a newborn who wants to nurse a lot but is still getting colostrum and not the mature milk that will encourage more wet and poopy diapers!

It was strange for me, to spend a night in the hospital without my baby by my side. It was also strange to visit him in the NICU, my otherwise big, healthy boy in there with the sicker babies who needed so much more care. We got off to a bit of a rocky start, too. He was there only about 45 minutes before he was brought back to my room, screaming. "He says he's starving!" my nurse said. I nursed him, then wheeled him back to the NICU to go back under the lights. The nurses there were trying to get him to take a pacifier, but he was protesting it.

I was advised that if he was going to need to eat so often, the lights wouldn't be very effective. The protocol was three hours on, 30 minutes off, but he wasn't willing to go three hours without nursing. And normally I would have been perfectly fine with that! A two-day-old baby shouldn't necessarily go three hours without nursing, both for his sake and for mine! His suckling encourages my milk production to increase, as well as nourishing him and stimulating his digestive system. I was happy to feed him every hour or two, but that would render our night in the hospital ineffective. I was frustrated, and so were they.

One of the nurses told me that giving him a little formula would probably help, since it would fill him up so he could wait longer to nurse again, and it would make him pee. Without peeing, he wouldn't clear out the bilirubin. "You have to decide what's your priority - breastfeeding or treating the jaundice," she said. I felt a bit threatened or judged, like maybe by clinging so hard to the "exclusively breastfeeding" mantra, I might be causing my baby harm or wasting my time (and hers?). I was taken aback. I had made it clear that he was not to receive formula, his case of jaundice wasn't severe (yet?), and I was educated enough to know that giving even one bottle of formula when supplementation wasn't medically necessary could cause long-term harm. But I'll tell you something, in all honesty: I almost gave in. I was desperate for him to stay longer under the lights. I was so nervous about "wasting" our extra night in the hospital. I really wanted this treatment to work. And if a couple ounces of formula was all he might need...I hesitated. I felt like I was already breaking so many "rules." Here I was, a trained Lactation Educator, on my fourth baby, a self-proclaimed breastfeeding advocate and expert, and my baby was spending a night in the nursery, being offered a pacifier, and now I was thinking about delaying feeds and supplementing with formula besides.

I gathered myself. "Breastfeeding is my top priority," I told the nurse. "I don't want to mess up his gut with a bottle of formula if he doesn't really need it." If my head had been more in the game, I would have known what to do immediately, but since I was groggy from two nights without sleep, thrown by this change of plans, and caught off guard by this sudden suggestion of formula, I couldn't think of a solution. "Maybe he'll go longer this time," I said, and went back to my room.

The first thing I did back in my room was Google "formula supplementation for newborn jaundice" on my phone (thank G-d for smartphones!). I thought I remembered reading an article from the Academy of Breastfeeding Medicine on whether formula supplementation for normal newborn jaundice was necessary or standard protocol, and I wanted to refresh my memory. I found exactly what I was looking for (PDF). In short, formula supplementation is not recommended for treatment of newborn jaundice unless there are other complicating factors. Short-term formula supplementation can have long-term risks. While it will help to clear the jaundice, it may interfere with establishing a good milk supply, may cause nipple confusion in a baby who is still learning to latch and breastfeed, and will cause the gut flora to be affected by introducing cow's milk proteins and non-breastmilk compounds into the developing digestive system. My Lactation Educator classes came back to me in a rush, and I remembered what we had learned about jaundice and supplementation. There are indications for short-term "interruption of breastfeeding" under certain conditions, but my baby and my situation did not call for such a drastic measure at this point.

And like that, I knew what I needed to do. I marched myself (figuratively) back to the NICU and found a different set of nurses sitting near my sleeping baby.

"Is the reason you'd want to supplement because you could feed him while he's still under the lights?" I asked.

"Yes," one of the nurses said.

"So, if I were able to pump some colostrum, you could feed him that instead of formula?"

"Sure. We do that all the time. Ask your nurse to get you set up with a pump. You can bring us whatever you pump."

I tracked down my nurse and explained what I wanted to do. She said no problem, and within the hour, I was set up with a pump and had started harvesting that precious, precious liquid gold. I felt if I could get at least 10mL (about a third of an ounce) in any given sitting, that should be enough to tide him over between the every-three-hour breastfeedings. I had a mild concern that giving him bottles might affect his desire and ability to latch, but I felt it was worth the risk. At least by pumping between at-breast feedings, I was giving myself the breast stimulation I'd need to establish a good milk supply, as well as giving Baby Y the colostrum he needed to keep him full and happy and able to pee and poop.

On my first go, I got 10mL from both breasts. Thrilled with my success, I happily delivered my first of what would be five 10mL bottles of colostrum that night. In between 30-minute feedings and 15-minute pumping sessions, I'd conk out, sleep for an hour or 90 minutes, to be awakened from a weird dream or a deep sleep by my nurse wheeling in a crying baby ready to breastfeed again. Tired but pleased, morning came and we eagerly awaited his latest blood test, to find out the result of our night's effort.

Liquid Gold

After 12 hours on the bili lights, at 51 hours of age, his bilirubin levels were down to 9.9, lower than they had been at the previous test, and down into the low intermediate risk range for his age. Yes!

We came home later that morning with instructions to have him seen by his regular pediatrician on Thursday. His doctor checked him over and decided that doing another blood test was not necessary. He told me to keep an eye out for more yellowing, lethargy, or not waking to feed, but as long as he was producing diapers, was waking up when he was hungry, and was feeding well, he was not concerned.

Thankfully, Baby Y's breastfeeding was not negatively affected by the use of a pacifier or by giving bottles. My mature milk appeared, on cue, at about 2.5 days postpartum, and he began gaining weight at an incredible rate. At hospital discharge, he was 7lbs., 14oz., about 8 ounces below his birth weight of 8lbs., 6oz. On Thursday, he was up to 8 pounds even, and on Friday, he had gained an additional 3 ounces in 24 hours, to reach a weight of 8lbs., 3oz. Though he has not been weighed since, I'm certain that he has surpassed his birth weight already, at eight days old.

In the next article, I'll discuss jaundice from a clinical angle. I am grateful that I had the experience and educational background to be able to effectively advocate for myself and my baby. Don't be afraid to do your own research and ask questions. When it comes to your baby's health and your breastfeeding relationship, it's important to speak up!

So, Which is Easier, Breast-Feeding or Formula-Feeding?

All right! Now that vacations out of the way and I can get back to a more regular blogging schedule, let's talk about that breastfeeding survey! I asked you to fill out a short, 10-question survey about your own exposure to infant feeding and your feelings about which is easier. I was actually fairly surprised by the results, and I think you might be as well.

I received 26 responses, not including my own. If you'd like to respond and haven't yet, I'll leave the survey up for a little while longer. I can revisit it in a few months and see if a greater number of responses alters or reinforces my conclusions.

The first two questions asked whether, in your experience or observation, breastfeeding and formula feeding are "very difficult, difficult, manageable, or easy." The majority of you answered, for both questions, "manageable," which was surprising to me. The second most popular answer for both questions was "easy." Overall, it seems infant feeding in general, be it by breast or bottle, is not considered a great challenge. Many responders felt the need to clarify or justify their responses by adding comments that different variables may affect their feelings, such as whether they work outside the home (making breastfeeding more difficult), or by stating that even if they thought breastfeeding was difficult, it's still worth doing. Two responders who felt formula feeding was difficult commented that it was because of all the bottle-washing.

And what do I think? I think formula feeding is very easy, if you have a baby who tolerates regular formula. I also think breastfeeding is easy, but there is a greater learning curve. I also think breastfeeding is not easy for everyone, for various reasons ranging from a physical problem with creating enough milk, to emotional difficulties, to a baby with physical or medical problems. All-in-all, having done both, I am going to come out and admit that formula feeding is easier in many ways but that I prefer breastfeeding on the whole.

The third question asked if you know how to properly prepare formula. I asked this because I think most people think they know how, but they may not be aware of the official guidelines to prevent bacterial contamination. The majority of you say that you do know how to prepare a bottle of formula properly. Certainly, preparing a bottle is not rocket science, but I was curious to see how confident we all were about our bottle-preparing skills. For the record, I knew the basics (how to measure, how to sterilize/sanitize bottles and nipples, how to warm the bottle). Some health authorities recommend boiling the water prior to use and not allowing it to cool below 70 degrees Celsius before mixing it with the formula powder. It is important to note that powdered formula is not sterile and is not safe for use with very young babies or babies with immune system compromise. Ready-to-use formula is sterile (but also considerably more expensive).

To contrast this, I then asked whether you know what a proper latch should look like when breastfeeding. Most of you say you do know, which is encouraging. The important thing to remember about your baby's latch is that it should feel right. However, if you're looking from the outside, your baby's lips should be flared outwards. The nipple should fall far back in the baby's mouth, so that a good section of the areola is in the baby's mouth as well. Many lactation consultants will advise you to try for an "asymmetrical" latch, meaning that the baby's lower jaw is closer to your chest than his upper jaw. The baby's chin should not be tucked into his chest, and his ear, shoulder, and hips should be in a straight line - his body should not be twisted, and he should not have to turn his head or strain to reach the nipple.

It really got interesting after this. The next four questions asked you specifically about your exposure to formula and breastfeeding aside from your own baby (if you have one). While most of you had often seen babies being fed from bottles, only about a quarter of you had seen babies breastfeeding on a regular basis. Several of you had seen bottles being prepared, and a third of you had prepared bottles for other people's babies. I was not surprised to find that there was far more exposure to bottle feeding than breastfeeding. Certainly the bottle is a pervasive symbol of babies and baby care in the Western world, especially the United States.

Finally, I asked you to decide which is easier, breastfeeding or formula feeding. The majority of you said breastfeeding is easier. Many who said that formula feeding is easier felt the need, again, to modify their responses by adding a comment that they still believe breastfeeding is better, even if formula feeding is easier.

What's interesting to me is that there was a definite reluctance to classify breastfeeding as difficult. I assume most of the respondents are breastfeeding advocates, experienced breastfeeding mothers (or their partners), or favor breastfeeding over formula feeding with their own children. If we say that breastfeeding is not easy, we may increase reluctance in giving it a try, especially among those who are specifically wondering which is really easier. Those who said formula feeding is difficult generally mentioned bottle-washing as a major turn-off. Those who wanted to comment as to what they found difficult about breastfeeding tended to allude to the difficulties associated with pumping and being "tied" to your baby.

I think this reveals a few basic issues in the "breastfeeding versus formula feeding wars." (By the way, the majority of you were not aware of this issue before becoming pregnant with your own baby.) The first is that there is still not enough general exposure to breastfeeding in everyday life. We need to see more breastfeeding in public, on TV, within our own families. Because of the strong formula/bottle-feeding culture in the United States and other Western countries, many children grow up never seeing a baby breastfeeding. Reinforcing this is baby dolls with bottles, the bottle as a symbol of "baby" in baby shower decorations, congratulatory greeting cards, baby birth announcements, and so on.

The second is that there is a perception that in deciding which feeding method to use, it matters which is "easier." I've written a couple of posts on this topic (for example, here and here). Many aspects of child-rearing are neither easy nor fun, while others are incredibly rewarding. What's important is not whether one is "easier" than the other, but which one is more beneficial to mother and child.

So is breastfeeding easier than formula feeding? In all honesty, no. It isn't. But both have their challenges, and the question is whether breastfeeding is overall more beneficial to mother and baby than formula feeding. And to that, I can say unequivocally, YES, it is.

Lynne's Birth Story - Jessica's Birth!

This is a very, very special blog post, written by my mom, about my birth and her breastfeeding experience with me. I'm struck both by how many similarities there are to giving birth 30+ years later, and also by what was different. Much of this should seem familiar to those of us who have had hospital births. There was far less breastfeeding support back then, but many of the challenges my mom faced are the same challenges faced by working women today. There wasn't much on the books at the time for breastfeeding mothers in the Navy, but my mother made her own rules! I hope you can see where I get some of my passion from in reading my mother's story.
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I really don’t remember why I decided that my baby would be born naturally and I would breastfeed. I’m the type of person who, when confronted with a new situation, will spend hours researching and reading, so it is possible that when I found out I was pregnant nearly thirty-two years ago, I rushed out and purchased as many books (no Internet) as I could find on childbirth and breastfeeding. I was greatly influenced by a book called The Immaculate Deception, by Suzanne Arms, published in 1975, which described the horrors of modern childbirth. I still have a copy of the book.  [Ed. note: This book is now out of print, but apparently the author wrote a second one: Immaculate Deception II: Myth, Magic and Birth, in 1994.]

Natural birth was becoming the “rage” in the early '80s, with hospitals opening up “Alternate Birth Centers” called “ABC rooms,” so I’m sure I was influenced by this trend, but there could have been other women in my life at the time who influenced me. As I said, I don’t remember. I do know that I wanted the very best for my baby, that she (I didn’t know it was a girl until she was born – no regularly-scheduled ultrasounds then) would have every benefit I could give her as she came into this mean, cruel world. I wanted her to be perfect.

I was (and I guess still am, but with less energy) a perfectionist and was not afraid of challenge or hardship, as I tended to push myself over the limit in everything I did. I was also extremely stubborn and tended to believe that if I wanted something, I would get it, so being an officer in the U.S. Navy at the time did not seem an obstacle to fulfilling my goals for my baby.

My pregnancy wasn’t anything interesting except for my high blood pressure, which the doctors passed off as nothing since it didn’t get any higher from my first prenatal visit. I gained more weight than I should have and I tended to eat a lot of chocolate but I exercised and did yoga. I expressed my desire for a natural birth and wrote up a “birth plan” to present to the attending doctor when the time came.

I worked passed my due date without a problem. That weekend, we went to a Triple A baseball game and fireworks at the stadium (the major leagues were on strike that summer). My water broke in the middle of the night and we called the hospital. They said to come right in. I knew that was a mistake; that I needed to stay home as long as I could and walk, walk, walk but I was also scared that something could happen with my water breaking so we trudged to the hospital in the middle of the night. I was only one centimeter dilated. They said that they preferred that I stay, because my blood pressure was high (no kidding), and I had signs of preeclampsia and a chance of infection, and we were too many miles away from home to turn around. I was admitted to a ward but I didn't want to just lie there, so my husband and I walked around the hospital campus for a while. I was hurting and scared and knew that I was starting out on the wrong foot, but I presented my birth plan to the resident. The poor guy; it was early in his rotation to OB, and he wanted to do well but was inexperienced, which is probably why he agreed to my birth plan. It included no drugs and no IVs or monitors so I could move around. I was hooked up to the monitors once an hour but was free to walk around the rest of the time. Ideally, when the contractions started and I was well on my way, I would gather my strength and all that I had learned from the myriads of reading materials and move around. Alas, I didn’t. I lay there for hours on my back, enduring the pain, which I could not believe was so bad, ignoring the breathing techniques we learned in our Bradley classes, but still determined to avoid drugs. I did not have an IV and did not drink anything, so I became dehydrated and the baby also. The doctor would come in periodically and check on me. He felt sorry for me and would induce a semi-trance to help me, which wasn’t helping since it reinforced me lying still for so long. My husband came and went, bored and scared.

The doctor did talk to me about a cesarean as my labor wasn’t progressing as quickly as it should have, but I declined. After twenty-six hours, on Monday morning, I was finally ready to push. I was transferred from the labor room to the delivery room. My husband was prepared with his camera but he had forgotten to put film in (no digitals then) so we don’t have a record of the birth. I pushed and pushed but the baby wasn’t coming out so the doctor took up his scissors (or whatever they were) and did the longest and deepest episiotomy on record (at least it seemed that way to my husband who nearly fainted, equating the sound to tearing a chicken wing in half) without asking. I had also been doing exercises to avoid an episiotomy but I guess they didn’t help. The baby slid right out amid a lot of blood and it was announced that it was a girl. I asked to have her on my chest and see if she would latch on but since her Apgar scores were too low, they let me have her for less than a minute and rushed her off to the neo-natal ICU. Not part of the plan but I was exhausted at that point.

I went to recovery and had to pee 1,000 cc’s before I could go to the ward. I requested that I be discharged as soon as possible, that I didn’t want to stay in the hospital. I had it in my mind to take the baby home right away, as I wasn’t sick and therefore did not need to be in the hospital. When the pediatricians visited, I told them I was going home and taking the baby with me. They said I could go home but the baby was in the NICU and wasn’t going anywhere. They had come to consult with me about her condition. She was extremely dehydrated and had “thick blood”. Her white cell count was elevated, suggesting an infection. They needed to take out half her blood and replace it with plasma because it was too thick to travel her veins and she was headed towards major brain damage if nothing was done, all because I wanted a natural birth, but I was stunned from the pain and the contractions into a trance and my doctor was too ignorant to compensate for the lack of modern intrusions like the IV for hydration.

I went home eleven hours after giving birth; the baby didn’t. I visited daily, tried to pump and tried to breastfeed her when they would let me, but they convinced me to start her on formula so she didn’t lose any weight so I agreed. She developed jaundice and spent five days in the NICU altogether before she was released. Luckily, she recovered completely.

I was still determined to breastfeed and started immediately. No one told me that babies can’t switch from formula to breast milk smoothly. She was up the entire night crying and pooping, crying and pooping. I knew nothing about the proper latch so every time she latched, I’d literally cry out for the pain. We finally settled into a routine and I tried to pump in between feedings (huh, she wanted to nurse all the time) in preparation for going back to work. I had six weeks off and decided to stay home full time for four of those weeks and return part time for four weeks, which was approved by my command.

I needed to pump and store the milk at work. I marched into my commander’s office and announced that I needed a private office so I could pump. It never occurred to me that he’d disagree; I was that sure of myself. He never said a word and I pumped until the baby was four months old and then had to start “supplementing” with formula as I couldn’t keep up with her demand. She nursed at night until nine and a half months and then stopped altogether, probably because I didn’t have enough milk.

In a way, that inexperienced doctor with a heart of gold did me a favor by not performing a cesarean, as there were no such things as VBACs then and I would have probably not breastfed (although I don’t really know), but there was also the real possibility of damage to my little girl because of my shock when labor actually came.

I learned a lot with her and knew a lot more when my son came along three years later. But, of course, my daughter is perfect!

About Those Formula Freebies and Mayor Bloomberg...

By now, just about every breastfeeding blog I read has made some kind of commentary or another on New York City Mayor Bloomberg's new program for breastfeeding promotion in NYC hospitals. Part of the Latch-On NYC initiative, this voluntary program requires that participating hospitals lock up formula, not routinely give out formula samples and formula-branded paraphernalia to new parents, prohibit the display of formula promotional materials in the hospital, and conform to the New York State hospital regulation that exclusively breastfed babies not be given formula supplementation unless medically indicated. The program is expected to raise breastfeeding rates in participating hospitals because research shows that women who are given formula samples by their doctors or in the hospital are 3.5 times more likely to be supplementing with formula by two weeks of age. If formula is kept under wraps, and new mothers receive education about breastfeeding before their babies are given any formula, the thinking goes, breastfeeding rates will rise and the overall health of the population will improve. Hand-in-hand with this is news of an AAP resolution that pediatricians should not routinely hand out free formula samples to patients, for the same reasons.

I have been reading every blog post I've been linked to, taking in almost every comment on all the major breastfeeding and parenting blogs I frequent, and I still don't quite know how I feel about this initiative. It sounds like they're basically trying to get NYC hospitals to conform to the Baby Friendly Hospital Initiative standards without going through the BFHI certification process. I gave birth to GI in a Baby-Friendly hospital, and I felt that the breastfeeding support there was excellent. Of course, I went in intending to breastfeed. If I had gone in less certain, uneducated, or sure I wanted to use formula, I'm not sure how I would have felt. I didn't need or want to ask for formula, so I don't know what kind of "lecture" or "education" I would have gotten had I made the request. I didn't have any problem nursing or producing milk, so I don't know how I would have been treated had I genuinely felt my baby was starving and needed formula supplementation. Because I've been lucky enough to be able to nurse with relatively few problems, and because I'm extremely pro-breastfeeding, well educated about breastfeeding (I literally wrote a book on it), and because I wasn't going to let anything or anyone stand in my way of breastfeeding, I didn't need to think about "the other side."

I often wonder whether I would have been able to breastfeed NJ had I given birth to him in a hospital like the one where I had SB and GI. Rather than jumping straight to formula when there was the slightest hint of a problem, if they had been more supportive of breastfeeding and, more importantly, had been more supportive specifically of me in my situation, would I have left the hospital breastfeeding instead of with an extra case of formula? It's very hard to say. My husband and I were discussing this last night (in the context of the above-mentioned controversy). His perspective and memories of those early days are different from mine, but we both remember that the lactation consultants who visited me were quite unhelpful. While it may have been true that many women who experience postpartum hemorrhage have difficulty with their milk supply, and while it may have been true that pumping often would help bring in my milk, what I really needed was to spend lots of time skin-to-skin with NJ, nurse him on demand, and be forced to care for him. Yes, I was weak. Yes, I had lost a lot of blood. Yes, I was in pain. But NJ was healthy and strong, had a great latch, and, with a little help, I probably could have initiated breastfeeding while in the hospital and breastfed him several times a day during that four-day stay rather than allowing the nursery nurses, my husband, my mom, and my visitors to feed him for me. It's probable that he would have needed a few bottles (or to be fed via syringe, perhaps?) on the first day when I was fairly down-and-out from blood loss, but on the second day? The third? Through the night? I do remember some good practices, such as telling me to save whatever I did pump and that they could give him that in a bottle instead of formula. They did provide me with a pump and show me how to use it. They did have lactation consultants come every day. But I constantly feel, looking back, that the advice the LCs gave me was, while not necessarily wrong, unhelpful or misleading. If you straight out tell a woman she won't have enough milk, why should she even bother to try? And if you don't tell her or her husband that formula is not, in fact, equal to breastmilk, then why shouldn't she just go straight to formula to begin with?

What's missing in all of this, to me, is that education prenatally is vitally important. The decision to breastfeed can't necessarily be made in the postpartum haze. The desire to stick with it is lowest when in the throes of newborn nursing, and the temptation to use that free formula is highest at the most critical period in the breastfeeding relationship. I know this. I've lived it. You need to walk into that hospital determined to breastfeed. You need a supportive hospital staff, from the OB or midwife to the delivery nurse to the postpartum nurses. You need lactation consultants on hand 24/7 (not just during business hours!). You need good, solid breastfeeding information. And you need to know that you are going to be respected for whatever choices you make.

The loudest complaints against this program seem to be from two basic viewpoints. One is the women who never wanted to breastfeed and don't liked feeling "shamed" or "guilted" by the hospital for their choice. The other is the women who desperately wanted to breastfeed but, for whatever reason, needed to supplement with formula in the early days and struggled long and hard with the decision. Both feel that formula samples are helpful, especially those that only needed a can or two of supplements before being able to go on to exclusively breastfeed. Both feel that being lectured or educated by hospital staff before someone will go get them a bottle for their starving babies is shaming and unfair.

The thing is, I agree with them, too. If my baby is starving because I can't produce enough colostrum or milk to satisfy him (please note that this is rare), then I need to be able to give him something else. If the hospital staff balk at giving me a bottle of formula to feed him, and I have to sign a form or justify my request every time my baby gets hungry, it's going to make me feel even worse and more inadequate. Support doesn't mean just patting a woman on the back and telling her she's doing a good job breastfeeding. Support means sitting down with a woman and figuring out what she wants, what her goals are, and then helping her get there. A good IBCLC knows this, and a good IBCLC will know when formula supplementation is necessary and how best to introduce, use, and wean off of those supplements, if possible. Having a nurse who's had a little bit of lactation training come in and tell you once again that formula isn't as good as breastmilk, and maybe you should have another go at feeding from the breast before you give a bottle, is only going to make a frustrated mother more flustered and upset. We need a balance.

I'm in favor of locking up the formula, but I'm also in favor of giving it to any mother who asks for it. I'm in favor of banning the gift bags and the formula-branded handouts, but I'm also in favor of giving unbranded formula to mothers who need it (in the hospital). I'm in favor of good breastfeeding support and information, but I'm also in favor of education in the proper preparation and use of formula, if a mother chooses to use it. I'm in favor of pediatricians having formula samples on hand to help out mothers who need it, but I'm also in favor of pediatric offices having lactation consultants on staff to help mothers who are struggling. Balance.

We need a more comprehensive solution. While restricting access to free formula will increase breastfeeding rates among those who are on the fence (that's been proven), it will not help those women who truly need it or who adamantly refuse to breastfeed. We need information and education throughout women's lives, and especially during pregnancy, to help them learn about breastfeeding before there's a squalling baby in their arms. We need postpartum support, especially for those women who are going back to work. We need support for pumping in the workplace. We need better, longer maternity leave. We need a cultural shift.

If there is one thing I know, unquestionably, it's that the more babies who are breastfed, the better. Banning formula freebies in hospitals and pediatric offices is a step in the right direction, but it's not the only step.

Breastfeeding: All or Nothing?

I read an interesting point in a blog post recently, and I only wish I could remember which blog, because I read so many and rarely keep track of who said what (bad blog reading, I know). In any case, the point was that while you can choose not to breastfeed, you can't then later choose to switch to breastfeeding. However, you can choose not to formula-feed and then later choose to switch to formula if your situation calls for it. Basically, you've got to start out breastfeeding, and then make the choice either to continue or let your milk dry up and switch to formula.

This isn't exactly true, of course. It is both possible to relactate - that is, ask your breasts to start making milk again after having let your milk dry up - or to induce lactation - that is, ask your breasts to start making milk even if you never even had a baby. Some adoptive mothers do the latter, inducing lactation by tricking the body into thinking it's pregnant and then tricking the body into thinking it's delivered a baby through the use of hormone therapy and 'round-the-clock pumping. It's not easy, and it doesn't work for everybody, but it can be a very rewarding effort if you wanted to go that route. As for relactation, it's nearly as difficult. It's possible to bring your milk back in within the first few months after giving birth if you pump about every two to three hours around the clock for several weeks, as well as putting baby to breast as often as possible (if possible), but it takes serious dedication. After my first son was born and had been on exclusively formula for about four weeks, I thought about relactating. I spoke with a La Leche League leader about it, and she said I'd basically need to treat my breastpump like a newborn, pumping at least eight times in a 24-hour period (including in the middle of the night). She also said that since I had never established a full supply to begin with, it might never be possible to do so. I gave it a half-hearted effort, but never really was able to extract more than a few drops of milk, and I gave up after a couple of weeks of seeing no change.

So if you think you probably do want to breastfeed but you're not sure, you should start out doing so. Bring in your milk, breastfeed your new baby, and if for whatever reason you decide you don't want to do it, or there is a medical or psychiatric reason that you shouldn't or can't do it, you can always stop, wean to formula or bottles of donated breastmilk, and let your milk dry up. But, if you don't bring in your milk and start breastfeeding, it's pretty darn difficult, if not impossible, to change your mind six weeks in.

So in the beginning, yes, breastfeeding is "all or nothing." That is, either you do it or you don't. But, once you've established your supply and the baby has learned to feed effectively, and you give it a few weeks, or months, or years, things become a bit more flexible. For example, let's say that after six weeks, your maternity leave ends and you have to go back to work full time. You intend to pump and have your baby drink your milk from a bottle while you're separated from her. This would be ideal if you can't be with your baby all day, which many, many women can't. But, what if you just can't pump enough milk? Some women's bodies just don't respond well to the breast pump, and they can't produce enough, or they can't produce anything at all, or they can't keep up with their baby's needs by pumping. Other women's jobs are not ideal for pumping milk. Even though new federal law requires most workplaces to provide adequate break times and space for pumping milk, it still may not be entirely possible. Does this mean you have to stop breastfeeding and give your baby formula?

No!

Certainly, and I stress this because I believe it, it is most desireable to feed exclusively breastmilk for at least the first six months of your baby's life. That is the general recommendation from the AAP, the WHO, and other health services. Breastmilk is the best food for your young baby, and if you can provide it, and you will provide it, then you should provide it. The enormous benefits to your baby's (and your!) health, from nutrition to immune system to brain development to priming the digestive system, make exclusive breastfeeding the natural choice for every baby.

However, some breastmilk is better than no breastmilk. If you simply cannot provide exclusively breastmilk to your under-six-month-old baby, then continuing to nurse as much as you can is still good! Even if that means you only nurse at night, or in the morning and evening before and after work, or three times a day, or just for bedtime, some breastmilk is better than no breastmilk.

After six months or so, once you've introduced solid foods, you are no longer exclusively breastfeeding anyway. The benefits of breastmilk never go away, of course, so if you can continue to breastfeed as your baby's major source of nutrition, you should go on doing so. But, if you've given it six months and you're going a little nuts, backing off at this point is not as harmful, since your baby is eating other foods anyway. Remember that solid foods cannot and should not replace breastmilk and/or formula as your baby's major source of nutrition until after 12 months of age. Especially early on, six or seven months of age, solid foods shouldn't be more than 5 to 10% of your baby's daily intake. By one year, solid foods may be up to closer to 50% of your baby's intake. After one year, solid foods can be the majority of your baby's caloric and nutritional intake. Between six and 12 months, if you do decide to breastfeed less, you should replace most of the feedings with donated breastmilk or formula, not solid foods. One to three small meals of solids should be fine, but babies still need breastmilk or formula to thrive at that young age.

The AAP recommends breastfeeding for at minimum of one year. The WHO says two years. By one year of age, many babies are eating a fair amount of solid foods. At this point, you can choose to wean without taking away a significant portion of your baby's diet. However, if you want to continue to nurse, you certainly can. There is no psychological or physical harm to continuing to nurse to two years or beyond. The value of breastmilk and breastfeeding is not diminished just because the Earth has circled the sun one time since your baby was born. But, toddlers can survive on solid foods, assuming you are providing a variety of foods to create a balanced diet for your child. Children under two still need milk fats for brain development, either from your own milk, cow's milk, other dairy products, or another source. I am not a nutritionist or pediatrician, so I can't make a recommendation about what sort of milk to feed your toddler to replace breastmilk, but most pediatricians will tell you to give whole cow's milk to replace breastmilk or formula after one year of age.

If you do decide you want to wean at one year, you may need to start cutting back slowly. What you may find is that once you're down to two or three feedings a day, instead of six or seven, for example, or once you find that you no longer need to pump at work, breastfeeding may become an enjoyable break, rather than a burden or responsibility. Cuddling up with your toddler to nurse at bedtime or for an afternoon snack may be a time of closeness you and your toddler need during your otherwise hectic days. At this point, breastfeeding really isn't all or nothing. Weaning doesn't have to mean stopping completely, and weaning can be a slow, gentle process. I know of women who continue to nurse just once a day for months before they or their child finally drop that last feeding. I also know of women who continue to nurse six times a day, or more, throughout the second year. I found that SB gradually cut back over the course of his second year, until he was really only comfort-nursing at night. By the time I cut him off at 25 months, I didn't even get engorged, he was nursing so rarely and so little. A slow weaning process is more comfortable for both mother and child.

I don't really feel comfortable encouraging anyone to cut back on breastfeeding until her baby is at least one year of age. I wouldn't be writing this blog if I didn't feel that women should be supported and encouraged to choose exclusive breastfeeding. However, I also don't think it's fair to insist on breastfeeding as the only right choice, as if you either breastfeed or you don't. I think that places a lot of burden and blame on women who, for whatever reason, choose to use some formula. I also think it's important to let women know that breastfeeding some of the time is better than not breastfeeding at all. Just like some exercise is better than no exercise, and eating some vegetables is better than eating no vegetables, and getting some sleep is better than getting no sleep, breastfeeding some of the time is better than breastfeeding none of the time. To keep some supply, you have to breastfeed regularly, but if, for whatever reason, you don't breastfeed all of the time, that doesn't mean you have to stop completely.

I've been thinking about NJ's early weeks on this Earth, where he was getting perhaps 3 ounces of breastmilk per day when I pumped for him. I asked my LiveJournal audience if that measly 3 ounces a day mattered. I wish someone had said, "YES! Any breastmilk is better than no breastmilk!" I wish someone had said to me, "Try just nursing once a day. Maybe you'll find you want to try for a second feeding, and then a third." I wish I had known I could combination feed, or bring up my supply over time, as I healed, rather than just stopping. I wish I had known how important it could be in the future. I wish I had known how badly I would feel about stopping.

It is those regrets that drove me to two successful VBACs and two successful subsequent nursing relationships. (I've officially made it to six months of breastfeeding with GI, and we started solids a couple of weeks ago but are still mostly nursing. I'll be blogging about that soon.) It is also those regrets, and my subsequent successes, that drive me to write this blog. So I say, Yes! Do breastfeed! Give it a shot. Give it six weeks.  Breastfeeding some is better than not breastfeeding at all. Some breastmilk is better than no breastmilk. And it is not all or nothing.

Most importantly, find help and support so that you can meet whatever goals you have set for yourself. Knowing that you've reached or surpassed those goals will allow you to look back with pride rather than with regret or guilt.

Feeding Other People's Babies

The other evening, we made a trip to the emergency room because my husband was sick. Fortunately, it wasn't serious, and he's fine, but it was an interesting experience. We left the three kids home with a sitter, hoping it wouldn't be more than a few hours that we would be there. Thank goodness I still had some pumped milk in my freezer from a couple of months ago. I left that and a bottle for the baby, left instructions and dinner for the older kids, and we were off.

While there, aside from worrying about my husband, my mind of course kept dwelling on whether GI was taking the bottle, hoping he wasn't screaming in hunger, hoping the other two kids went to bed nicely, hoping everyone was fine. I didn't get overly engorged - we were there about four hours, so the baby would only have eaten once, maybe twice, in that time anyway - but I did have two let-downs while we were sitting there.

As an aside, I will say straight out that the biggest inconvenience in breastfeeding is that you are tied to your baby. GI would not, in no uncertain terms, take the bottle from the sitter, and so was ravenously hungry when we got back from the ER. If he were regularly bottle-fed, there would have been no problem. However, the incredible benefits to breastfeeding far outweigh, to me, the occasional problem of not being able to be away from him for more than a couple of hours. And, certainly, if I were regularly away from him and regularly pumping, and he was regularly eating from bottles, it wouldn't really have been a problem either. Since I'm with him all the time, I don't have the patience or desire to pump and store milk and have someone else feed him when it really is easier just to nurse him. Other women do prefer to pump milk and have someone else (say, Dad) feed the baby once or twice a day (or night), and that's perfectly reasonable as well, as long as your supply is fine and the baby doesn't have a problem switching between breast and bottle.

But back to the story at hand. The way the emergency room was set up, we could pretty much hear what was going on with most of the other patients behind the other curtains. At the far end of the room, there was a woman with her husband, mother, and newborn baby. The woman had had a c-section, and I assume she was in the ER for some reason related to that. I couldn't hear everything they said, but I felt bad for her. I've been in that same situation. I heard the baby making rooting noises and fussing, and then I heard the nurse tell the mother that she couldn't breastfeed for 24 hours. I almost wanted to offer to nurse the baby for her. I had all this milk collecting in my breasts, and she had a hungry newborn who she couldn't nurse. I decided it would have been too weird to approach a random stranger in the ER and offer to feed her baby, and then the ER nurse brought over a bottle of formula for the baby, but the whole thing made me sad. First of all, even though they tell you not to breastfeed for 24 hours after they give you certain medications, it is often not true that those meds are incompatible with breastfeeding. It's important to check. Find out what they gave you and then do your own research as to whether it's okay to breastfeed. Secondly, since they knew she was breastfeeding, it would have been nice if they gave her meds that they know to be compatible with breastfeeding so there wouldn't be a problem. And, finally, that early in the breastfeeding relationship, giving bottles of formula for a day can be a great stress on the success of future breastfeeding. I'm not saying that being in the ER ruined this woman's ability to continue breastfeeding her daughter, but it certainly made it harder.

As far as offering to feed her baby, well, I've never actually nursed someone else's baby before. I know there are some women who set up baby-sitting shares, where they'll watch each other's babies and even nurse them. But, more often, if you are helping to feed someone else's baby, it's by pumping and donating milk to her, rather than directly nursing her child. I have donated milk in the past, with my abundance after SB was born, and I had every intention of doing the same with my similarly abundant supply with GI. This time, I find it difficult to pump even once a day, with three kids home all the time, so I didn't keep up with the pumping and now just have a small freezer stash. There were two women I thought I would be donating milk to, and I think that if I knew there was someone depending on me to pump for her, I would have, but neither one wanted my milk in the end, so I haven't been doing it.

Aside from donating to personal friends or acquaintances, you can also donate your milk to a mother in need who you don't necessarily know in person. There are a few informal milk-sharing groups out there, where a woman with milk to donate can be connected directly with a woman in need of milk and they can make arrangements for the direct donation of milk between mothers. It's pretty neat. These include Human Milk 4 Human Babies, Milkshare, and Eats on Feets.

You can also donate excess pumped milk to a milk bank affiliated with HMBANA. They have a screening process to make sure your milk is healthy for the preemie babies it is usually fed to. This usually just involves a blood test and a questionnaire to make sure you are healthy and not using any medications that might be harmful to a baby.

So, why donate milk, anyway? Isn't that kind of... gross?

First of all, milk is milk. Human milk is meant to feed human babies. And while the best milk for a given baby is his own mother's milk, any breastmilk (provided it isn't carrying a life-threatening disease or harmful chemicals or drugs, of course) is better for any baby than artificial milk, excepting very specific and special circumstances. The hierarchy of the best food for a young baby is: 1) His own mother's milk directly from the breast; 2) His own mother's expressed milk; 3) Expressed milk from another woman; 4) Formula/artificial baby milk.

Thus, if a woman is unable to produce enough milk herself to feed her child, the most desirable alternative for feeding that baby is donated human milk from another lactating mother. There are many women out there with excess milk in their freezers, or women who desire to do something useful with their life-giving milk, but they don't know what to do with it or who to give it to. I hope naming those resources above will be helpful.

Why donated milk instead of formula? Isn't formula good enough?


Well, yes and no. Formula is adequate to give your baby the nutrition he needs to grow. However, there is so much more to breastmilk than just nutrients, and more and more studies about breastmilk show that breastmilk is about far more than just feeding. To put it very succinctly, babies are born without gut bacteria. We need to populate the gut with the "good" bacteria, that help digest food and protect against infection. Human milk works in various ways to promote the growth of good bacteria, prevent inflammation and tissue damage to tender newborn guts, and to directly protect against invading infectious agents. Formula does not do any of these things. Young babies who receive even one bottle of formula in the early days and weeks of life will have a different gut flora (population and type of bacteria) than exclusively breastfed babies. This can cause inflammation and other undesirable effects on the "virgin" gut of a young baby. (Please note, the "virgin gut" can be reclaimed by exclusively breastfeeding, but it takes time, something like 6 weeks.) Once you introduce solid foods, the gut is no longer "virgin," anyway, but in those first six months, and especially in the first 10 days before the baby's immune system starts up, breastmilk is very important. Formula is adequate, but breastmilk is normal. Please see this excellent explanation from the Lakeshore Medical Breastfeeding Medicine Clinic and Dr. Jenny Thomas, MD, IBCLC, FAAP, FABM (how's that for a bank of initials after her name!).

It wasn't so long ago that it was reasonably common to for one woman to nurse another's baby. In other cultures, it still happens. Human milk is human milk, after all, and doesn't it make more sense to feed a baby milk from another woman of his own species than the milk from a totally different animal?

I've thought about it a lot over the course of nursing two babies, and I think that, if I were asked, I would happily feed another woman's baby. That's assuming, of course, that the baby would be willing to have me nurse him! I certainly would have no problem pumping a bottle for another baby if I were asked to help out.

By the way, it is possible to ship frozen breastmilk, although the less time the milk is out of a freezer, the better. I once shipped milk overnight from California to Florida in the middle of summer and it was still usable when it arrived, but we cut it kind of close. Donating/receiving milk locally, where it would only be out of the freezer for a short while, is preferable. The Milkshare website has a good couple of pages on storing, freezing, and shipping breastmilk intended for donation.

And remember that supply is governed by demand, so if you do decide you want to start pumping and storing for donation, you should be able to increase your supply over time in order to continue to provide milk for your own baby as well as putting some aside for another baby in need.

Breastfeeding a Newborn

I'm back in the "breastfeeding a newborn" phase of life. Actually, the new baby has been amazingly good to me. I've written about how my second son was a snacker, eating every hour. This new guy, he eats very enthusiastically, sometimes only for 10 minutes, other times for 20, but he cluster feeds for a bit, then takes a nice long nap, sometimes close to two hours. (Not that I can make any definite statements about his habits at 17 days old, but this is sorta how it's been so far.) It's kind of amazing. I was prepared for another every-hour eater, so this is pleasant.

Before my milk came in, his latch was horrible, it was hot as heck here (no A/C), and he would not let go of my nipple without screaming. I dreaded latching him on, I cried, thinking I couldn't possibly handle a baby like this, I despaired. And then my milk came in, and he became the most content, easy-going guy. I'm very lucky.

I read a very good article yesterday - which I wish I'd read two weeks ago! - about how positioning is more important than how the latch looks, and how the latch feels is more important than it looking like they describe in the books, and suddenly he's latching better, with just a few simple tips. Hold the baby tummy-to-tummy with you, so his ears, shoulders, AND HIPS are in one line. Bring the baby to your breast, with the nipple in line with his NOSE, and let your breast brush his CHIN. This will stimulate him to open his mouth, and then you can drop the nipple in. If it doesn't hurt, you're fine. Also, it helps keep him latched comfortably if you recline a bit. This is called biological nurturing, or laid-back nursing, and it helps keep the baby from flinging his head backward and coming off the nipple in a rather painful way.

I would like to brag a little at this point. Baby was born 8lbs., 3.5oz. By day three he had lost about 6 ounces, and was down to 7lbs., 12oz. The very next day, day four, he was up to 7lbs., 15.5oz. (yes, he gained 3.5 ounces in one day, once my milk came in). Today, he had his two-week appointment, and at 17 days old, he's 9lbs., 14oz. Yes, folks, he gained over two pounds in two weeks. He's a good eater, that one!

Anyway, I have mastitis. I've preached up and down, here and in my book, about getting rid of plugged ducts and avoiding mastitis, and here I wake up yesterday morning with a horribly engorged right breast, chills, achy joints, and a hard, sore spot on the outside of said right breast. Damn. I tried my usual tricks, massaging the spot while nursing, nursing a lot on that side, letting the hot water from the shower help open up the duct, massaging some more. I thought I'd taken care of it, until my 600mg dose of ibuprofen wore off and the chills came back last night. I spent the night alternately having chills and sweats, so I called the doctor this morning and asked for antibiotics. If you can't clear the infection with home remedies within 24 hours, it's not worth taking any chances. Mastitis can be serious stuff. I was hoping to avoid antibiotics, because that can lead to thrush, which is its own ball of trouble. Ah well. I got some probiotics to take along with the antibiotics, so hopefully this will be the end of it.

And, finally, I've decided to start pumping and storing breastmilk again, like I did with my second son, in order to donate it. I have someone in mind to give it to, if she wants it. A friend of my housekeeper's had a baby who was in the hospital for a few weeks after birth. She desperately wanted to breastfeed him, but she didn't have good support, and she didn't have a full supply established. I tried to pass along some tips, but I think it was too late. At three months old, now, her milk is dried up, and her son has had four ear infections already. She's terribly upset. I asked my housekeeper if she thought her friend might take donated milk, and said I'd be very happy to start pumping for her. I won't be able to give her enough to get him off formula, but even one bottle a day may help. Poor baby.

Breastfeeding Basics - Part IV: Six Weeks to Six Months

By now, you've read the Introduction and Parts I, II, and III of this series. I hope that you're finding breastfeeding and mothering in general to be getting easier.

I debated how to divide up the next few sections. I considered doing a post just on the next six weeks, up through three months, and then do a three to six month post. But, I chose to combine these because most of the issues I want to cover could come up really at any time, from birth to six months, and not that much changes from here on out until you start offering solid foods (to be covered in the next part). What I'll do, then, is divide Part IV into two subsections, up through three months and then up through six months, and then cover the more universal issues that may arise.

Six Weeks to Three Months


By now, you've weathered at least two growth spurts. When you come out of the six-week growth spurt and into "after the first six weeks" territory, you'll realize how much your baby has grown. You'll notice that he nurses more effectively, probably for a shorter amount of time, and, if you're lucky, maybe less often as well. In the next six to eight weeks, your baby will start smiling (if he hasn't already), laughing, showing better and better head control, showing interest in grabbing items, and recognizing and showing delight in human faces, especially those of his close family. His hunger signals should become more obvious and readable to you, and you're probably starting to see some real personality emerge. Your baby isn't just a needy lump anymore (no offense, but, really, in those first few weeks, they don't do much but eat, sleep, cry, and poop, right?). He's an enjoyable human being in his own right, and you can actually start to play with him and interact with him.

In addition, you are starting to feel more like yourself again. Sure, you're probably feeling sleep-deprived, but the major aches and pains and soreness and general not-yourself-ness you felt after the birth should be greatly improved. Your postpartum bleeding should be done with or mostly done, you've been back for your postpartum visit with your OB or midwife, and you're much more up-and-at-'em than you have been since the baby was born.

This is a good time to point out the symptoms of postpartum depression. This is only tangentially relevant to this blog post, so I'm pointing you elsewhere for detail. Basically, if you're feeling melancholy, depressed, overly anxious, having disturbing thoughts or desires about harming yourself or your baby, strong feelings of guilt or failure, etc., please seek help. These feelings are not normal and you don't have to live with them or expect to "snap out of it" on your own. There are plenty of resources out there to help identify, diagnose, and treat postpartum depression (PPD), and many of the medications used for the treatment of PPD, if needed, are safe for breastfeeding.

By the time you reach about three to four months postpartum, your milk production should have largely adjusted to the needs of your baby. You'll find you're feeling engorged less often, if at all, and hopefully leaking less (if this was a problem for you to begin with). You may also find, if you're pumping, that it's harder to produce as much for the pump. This is all due to the switch-over from hormonally driven production to demand-based production. In the first phase of breastfeeding, milk production is stimulated and controlled by hormones. As time goes on, the automatically-produced hormones cease, and your baby's demand - the amount of milk she takes in and the frequency of her feedings - instead stimulates the breasts and brain to produce milk in line with what your baby needs.

Be forewarned that there is another growth spurt around three to four months of age.

Three to Six Months


Now is the time to sit back and enjoy the progress you've made. Making it to six months exclusively breastfeeding is a great accomplishment! In these three months, just keep nursing on demand. Don't worry about giving water or other foods. Just nurse your baby when he's hungry!

During this time, you may find your baby is developing some annoying habits. Some babies will suddenly decide they only like to nurse in certain positions or places. Many babies become very distractible around four months of age because they've suddenly become aware of the world around them and want to participate. It can definitely be frustrating to have the baby pop on and off the breast constantly while nursing. Whenever practical, you can nurse in a darkened, quiet room to minimize distractions. At least this way, he'll get a good meal in a few times a day, even if the rest of the day is more erratic. As he gets more used to the world "happening" around him, and he starts to make the connection between popping off the breast and being hungry, he should become more reliable again.

Also during this time, your baby will probably start teething. Symptoms of teething may include excessive drooling, difficulty finding a comfortable position lying down, suddenly refusing to nurse, wanting to nurse more, chewing on hands (or your nipples), chin or cheek rash (due to the drool), diaper rash and mucousy poop (due to swallowing excess saliva), stuffy nose, mild fever (not higher than about 99 degrees Fahrenheit), red, inflamed gums, ear infection or ear ache, difficulty sleeping, and general fussiness. Some babies show almost none of these symptoms, while others may have all of them. Teething can make nursing difficult for both of you, as it may hurt him to suck, and his latch may suffer as he tries to adjust his latch to the changes in his mouth. Also, these symptoms may go on for weeks before a tooth actually comes through. It's usually not quite as hellish as I'm making it sound here, and you'll find effective ways to help soothe and calm your baby. It may be as simple as allowing him to chew on a cool washcloth, or you may want to give him Infant Tylenol (as directed!!) to help dull some of the pain of teething. Once the tooth comes through, you may have to help him readjust his latch once more so that it's comfortable for you.

Bottom teeth should never come in direct contact with your breast, as a baby with a proper latch should put his tongue over his bottom teeth. The top teeth should rest only lightly on the breast and not dig in. If you have tooth marks on your breast, you may need to help him readjust his latch. Often, he will adjust it on his own in a day or so as he figures out what to do with this new thing in his mouth.

If your baby bites you during this time, it is typically not meant aggressively. He may just be seeking relief from the teething symptoms. The best way to deal with biting while nursing is to immediately put the baby down, make an exaggerated sad face, and say "No bite! That hurts Mommy!" Then allow him to nurse more. If he associates biting with not nursing, he should stop biting. If you yelp or make a funny noise but don't withdraw the breast, he may think it's funny and start biting more often just to see your reaction. It's difficult, and it hurts, but you definitely want to stop this behavior quickly if it happens.

Common Issues


Thrush
Thrush is an infection caused by yeast. Thrush can be present on your nipples or in the baby's mouth or both. It is passed back and forth by nursing. Symptoms of thrush in the mother may include suddenly very sore nipples, especially at latch-on, pink or red or scaly nipples, cracking or bleeding nipples despite no change in baby's latch, a burning sensation within the breast during nursing or let-down, concurrent vaginal yeast infection. Symptoms of thrush in the baby include whitish patches in the mouth that do not wash away, pain in the mouth, excessive gassiness if the yeast invade the digestive tract, yeasty diaper rash. Mother and baby may show some or all of these symptoms, possibly not simultaneously. It can be very difficult to positively diagnose thrush.

There are many treatments for thrush. Some work better for some people. You may need to work at it for a few weeks to find the best treatment for you and your baby. Options range from prescription Nystatin (either cream for you or an oral suspension for baby's mouth and for your nipples), over-the-counter Monistat or Lotrimin (cream to apply to your nipples), gentian violet, grapefruitseed oil, or a combination of the above. A good place to get ideas for how to identify and treat thrush can be found here.

Plugged Ducts and Mastitis
A plugged duct is exactly what it sounds like - when a milk duct become clogged with solidifying milk. This usually occurs due to unresolved engorgement but can happen any time, especially if your baby has gone longer than usual without nursing. It can also occur if you are wearing restrictive clothing such as a bra with an underwire that is not properly positioned.

A plugged duct must be treated, as it can lead to mastitis, which is an infection of the milk duct. Untreated mastitis can lead to abscess or even loss of milk. It is important to identify and treat plugged ducts and mastitis promptly.

A plugged duct feels like a sore spot on the breast. I associate the feeling of a plugged duct with the way a bruise feels or a tender muscle after a cramp or strain. It will be a single spot on your breast, and you can usually feel a lump at that spot if you prod with your fingers.

To treat a plugged duct, nurse on the affected breast as often as possible (but don't let the other side become too engorged!). You can also pump or hand-express in between feedings. Keep the breast as empty as possible. Massage the affected area as you nurse and pump to encourage the plug to break free. Apply moist heat to the site of the plug to encourage milk flow. Direct the hot water from the shower to the breast as well, and massage while applying heat or in the shower. Get plenty of rest and drink lots of fluids to keep your immune system as strong as possible to fight off infection. After about 24 hours, you should find yourself feeling better. Sometimes the site of the plug may feel tender for a day or two after the plug is released.

Symptoms of mastitis include general fatigue, possible fever, increased pain in the affected breast, redness on the outside of the breast that corresponds to the site of the plugged duct, and flu-like symptoms. These symptoms usually come on quite suddenly and in conjunction with a plugged duct. Begin treating the plugged duct and rest and drink plenty of fluids. If your home treatment is effective, you should feel better within 12 to 24 hours. If your symptoms get worse, or you do not feel better within 24 hours, call your doctor, as you may need antibiotics to help clear the infection.

Pumping and Storing Milk
You may need to return to work after six weeks, or you may decide that you'd like to be able to be away from your baby during the day for other reasons. If you plan to continue exclusively breastfeeding, you'll need to pump and store breastmilk for the baby to eat while you're away. It is best to start pumping a few weeks before returning to work. I'm not going to get into a lot of detail here, as this is meant to be short. I'll just give you a few highlights.

1. Pumping takes practice. Your body is used to responding to your baby's sucking, not to a pump. You'll need to figure out ways to stimulate let-down with the pump. Some helpful hints include keeping a picture of your baby with you when you pump, relaxing as much as possible while pumping, not looking at the pump while using it, having something nearby that you associate with nursing (even a video or audio recording of your baby on your phone can help!). 
2. You want to pump more than you need. You may not want to have too much more than you need, but you may have "off days" where you don't produce as much, or you might spill your milk one day (boo!), or you might have a mommy-brain moment and forget to properly refrigerate your milk, or your baby may suddenly be extra-hungry one day and drink more than usual while you're gone. Having extra milk in the freezer as backup will be helpful!
3. Pump on a schedule. If possible, pumping on a regular schedule will mimic your baby's reasonably regular feeding habits, stimulating your breasts to produce the milk you need when you need it.
4. Storing milk: Breastmilk can be stored at room temperature for four to six hours, in a fridge for up to three days, in a standard freezer for four to six months, and in a deep freezer for six to 12 months. You can store milk in the most convenient way for you, in a bottle, milk storage bag, ice cube tray, or whatever other solution you find. Make sure the receptacle is clean and can be frozen safely (if you're putting it in the freezer).

Keep at it! You've made it through the hardest part. In the next section, we'll talk about introducing solids and what to expect as your baby approaches her first birthday!

My Nursing Story

First of all, on a totally unrelated note, I'm supposed to have my major anatomical ultrasound tomorrow (20 weeks!), and I'm terribly excited to find out if my boys are getting a brother or a sister. Hopefully baby will cooperate. I'll be sure to let you know as soon as I can. :)

Obviously, I don't have a nursing story about my first son, except what I've already written about. But I nursed my second son until he was 25 months and stopped because I needed to and he was ready. It's hard to remember all the details going back to when he was born, but I want to share with you my experience as best I can. I feel I had a fairly middle-of-the-road nursing experience. Nothing too dramatic, no major struggles, but some frustrations and idiosyncrasies that might make someone else in the same situation feel a bit better about what her baby is doing.

Because I'd had so much trouble the first time with not having all the right information, with my traumatic birth experience and hospital re-admittance, with my general dislike of the brief nursing episodes I had, and without someone to take the journey along side me and encourage me, I was terrified of what might happen the second time around. I had resolved to move mountains to make it work this time if I had to. I knew all about handling food intolerances, avoiding nipple confusion, and I was ready to take on whatever challenge was thrown at me. I hoped.

It turned out, most of my emotional girding wasn't needed, thank goodness. But it's good to know these things even if you don't need them.

When the birth went smoothly and he latched on to my breast for the first time and didn't let go, I knew I had experienced a miracle. The incredible differences between the births of my two sons still fills me with wonder. I think because I was so committed to breastfeeding the second time, I didn't let "difficulties" get me down. That's not to say I didn't get frustrated with marathon nursing sessions, or that I always loved that I couldn't be away from him for more than an hour at a time, or that I liked hardly getting to sleep through the night for over two years. But at the same time, every time I squirted milk at the shower wall in the morning, every time I woke up to a soaked bed (until I started sleeping on a towel), every time I found a new way to nurse more comfortably while I went about my business, I smiled. I smiled because I was so thrilled that my body was doing exactly what it was supposed to do, and I was giving my son exactly what he was supposed to have.

So. As I recall, for the first few weeks, he nursed pretty much every hour during the day. That is to say that sometimes I got no more than a 20- to 30-minute break in between nursing sessions. I had enough milk that he only needed to nurse on one side in any given nursing session, which was kind of nice. I did have a little trouble with his latch in the beginning - he was a bit lazy about always opening his mouth as wide as he should, and I was a bit lazy about correcting him. When you're nursing so often, you just want to let him eat and be done with it. I did go see a lactation consultant when he was about three weeks old, and she showed me how to fix his latch and told me more about the practical side of breastfeeding than I had learned in the two preceding years. I highly recommend taking an actual breastfeeding class before your baby is born, or scheduling a consultation with a certified LC if you think you're having any problems. Sometimes a simple 30-minute consult can make your life with your newborn oh-so-much more bearable!

I tried using a Boppy pillow for support at first but found it cumbersome. I'm...er...reasonably well-endowed, and therefore I was actually more comfortable just sitting cross-legged on the floor and letting his bottom rest in my lap than I was surrounding myself with pillows sometimes. As the baby gained strength in his neck and jaw, he was able to keep himself latched more easily, which meant I could nurse one-handed and surf Facebook or whatever while he nursed. I used to make sure to get in some computer time whenever he was nursing on the left side (so my right hand was free to use the mouse!). This was also a good time to sneak in a meal for me!

For the first few days, I swore I wouldn't co-sleep. I didn't want to get "trapped" into having him sleeping in my bed for three years. But most nights, I'd pull him into my bed to nurse him and fall asleep that way. I remember waking up an hour later and he was still there, latched and happily sucking. So I gave in and "admitted" that I was co-sleeping. He nursed a lot at night, but also a lot during the day. He was what they call a snacker. Lots of little meals instead of a big meal every few hours. It seems this is actually more biologically "normal," but it isn't exactly "convenient." As it were. He's actually kind of still that way, liking to eat snacks and small meals throughout the day rather than sitting down and eating a big meal for breakfast, lunch, and dinner. I guess it's just in his personality.

I did try introducing bottles of expressed breastmilk and a pacifier at four weeks of age (the recommended age to start introducing artificial nipples). He didn't take well to either, although I admit that I didn't push hard with the pacifier because my first son was still addicted to his and still used it 'round-the-clock when he was two years old. I didn't want that to happen again. So, though it resulted in my becoming a "human pacifier" (oh NO!), I did end up with a kid who doesn't use a pacifier. I'm still, 28 months later, not absolutely certain how I feel about that.

As for bottles of expressed milk, in the few weeks after introducing the bottle (and having my husband or mother-in-law feed him), he would drink fairly well, but after mostly being alone with me all day and not needing one, he pretty much rejected it. I still kept milk in the freezer on the off chance that he would take it once in a while if I had a baby-sitter, but mostly the milk collected in the freezer and didn't get used. I think I mentioned before that I donated a few hundred ounces to other moms, and I'm very proud of that and hope to do it again in the future. I also found that expressing and storing was a pain when I could just simply nurse him instead.

Digression: I know some moms like to take a bottle of expressed milk with them when they go out, so they don't have to stop and nurse while running errands, but I found stopping to nurse less trouble than expressing, so it wasn't for me. I'm not saying you shouldn't do it if it makes you more comfortable, though. The main thing to remember is that whenever you give a bottle of milk, you're signaling your body not to have a feeding at that time. If it's not a regular thing, then it shouldn't affect your supply. But, if you always give a bottle at, say, 10:00pm, then you might find that you don't have much milk at 10:00pm if you want to just nurse at that time instead. Most experts recommend pumping near a time when the baby is receiving a bottle so that your body knows to continue to make milk at that time. (Obviously, different advice applies to mothers working outside the home who have to pump to provide expressed milk for their babies to eat while they're at work! I'm not really talking about that here, although I may discuss it in a future post.)

Figuring out how to nurse in the mei tai (front carrier) helped immensely. One gloomy Sunday when my husband was at work, I was trying to figure out what to do with my two kids. We had a zoo membership at the time, so I decided to brave the zoo alone with two kids. I put the baby in the mei tai and took the stroller for the toddler. We were watching the zebras for a while, with no bench in sight, when the baby got hungry. I found a way to pull down my shirt collar far enough for him to get boob access, and I nursed him right there standing watching the zebras. That opened up a whole new world for me. First of all, no one around me even knew what I was doing, and it meant I was still mobile and accessible to my 2-1/2-year-old who wanted to continue exploring the zoo!

I wasn't squeamish about nursing in public (NIP) even though I expected to be. I found very quickly that my attitude was, "Baby's hungry. People would much rather see me feeding him (or avert their eyes) than to hear him screaming." Plus, I found that when we were nursing, I felt like I was in a little bubble. Even though I was aware that there were people around me, I didn't care what they thought. And you know what? I didn't get a single negative comment, a single impolite stare, I was never asked to leave or move to a more "private" location. My NIP experiences were always either neutral or positive. I'm grateful for that.

The couple of times I did manage to get away for more than a couple of hours, I ended up with a plugged duct after missing a feeding. OW! Fortunately, I was able to get them to release relatively easily. Only once, I ended up with the beginning of mastitis, but fortunately I was able to identify the symptoms for what they were and take care of it before I needed any medical treatment. Treating plugged ducts and mastitis deserves a post of its own. If you have a pressing question, though, please feel free to ask in the comments!

Anyway, people kept reassuring me that their babies nursed every hour like that for three months and then spread out their feedings after the three-month growth spurt. Or that they nursed like that for six months and then spread out their feedings. Or that once they started solids, you could put them off longer between feedings.  Well, my son continued to nurse about every hour until he was seven months old, when he finally stretched out to every two hours. He pretty much never slept more than a three-hour stretch, even past one year of age. I wasn't as proactive about giving solid foods as I thought I would be, finding it ever-so-much easier just to nurse than to set him up in the high chair to feed him. Plus, he decided he'd much rather feed himself "real" food than have someone shove purees into his mouth with a spoon, so it was hard to get a full meal into him until he was a bit older, anyway.

A few times, I attempted to teach him to fall asleep "by himself," i.e., without a nipple in his mouth. I failed every time. I finally decided that he wasn't going to stop nursing at night until he stopped nursing altogether, and by the time he was 25 months old (and I was one month pregnant!), he was really only nursing at night, and hardly at all during the day anyway. At some point, I realized he had started eating solid foods on a regular basis and only nursed mostly for comfort and not for nutrition. Sure, I enjoyed that he was still getting the benefit of my antibodies and the healing power of the milk, but he was nursing so rarely and getting so little that it ceased to matter. In fact, when he had a double ear infection on his second birthday (poor baby!), I knew he really wasn't getting much milk anymore. I prayed for a good night's sleep more often than once in a blue moon, and I knew that, being pregnant, I needed it more than ever. So, one day in January, he nursed at about 5:15am and then not again the rest of the day. When I put him to bed, I refused to nurse him and told him that the milk was "all gone." "All gone?" he asked, with wonder. How could there be no more? But I gently told him again that the milk was "all gone," and that he needed to go to sleep. I lay with him until he fell asleep. He awoke a few times during the night for the next few nights, asking to nurse, but he was finally convinced that there was no more milk (and there really wasn't after a point), and started falling asleep on his own. He still woke a few times during the night for another few weeks, but now, for the most part, he sleeps through and falls asleep on his own, with no formal "sleep training" from me. In fact, my two sons have about the same frequency of night wakings, and they were "sleep taught" very differently. It's kind of interesting. I'll probably talk more about sleep in another post, since it's an important topic that deserves more attention than I can give in this paragraph.

Anyway, he slept in our bed until he was a year old, at which point I put him in a crib in a room with his brother. That meant I had to get up and go to him every few hours, and we would nurse on the floor and then I'd put him back in his crib. That was hard, but the advantage was getting to sleep in whatever position I wanted in my own bed! It's a trade-off. I think a year was a fair amount of time for him to sleep with us, though, and it did get frustrating not to have the bed to ourselves.

The other reason I finally weaned was that I was getting recurrent bouts of what I think was thrush about every month for about a week. I would get it cleared up and then it would come right back. It never affected him, but it became very painful for a week or two out of every month to nurse him, and I got tired of not being able to completely get rid of the nipple pain, whatever might have been causing it. The pain of latching the baby on when you have thrush or other nipple pain is kind of indescribable and is enough to make you dread a feeding. This is another topic I'll cover more in-depth in a future post.

I'm not really complaining. Yes, I hope this next baby is "easier" in some sense. I hope that she or he nurses less often and likes food more and sleeps better. But at the same time, I know I can handle it and make it work for me if I have to, even with two other kids to chase around. Yikes?

I think it's all about attitude, really. I was so grateful to have a successful nursing experience, and I saw every ounce of milk I produced as a miracle. It was such a rewarding and wonderful time, and sometimes I do miss just cuddling up with him and letting him nurse. Sometimes I'm sad that he doesn't really even remember nursing and simply stopped asking for it after a reasonably short time. But, I'm looking forward all the more to nursing this next baby, for all the same reasons!