Our Breastfeeding Journey

A few weeks ago, we sent out a call for Breastfeeding/Chestfeeding/Pumping memoirs.  Our desire was to flood the Internet with beautiful breast/chestfeeding and pumping stories of triumph, overcoming challenges and struggles, and positive outcomes, regardless of the total amount of milk a parent was producing.  We are thrilled to share these stories with you, our readers, and hope that they offer support and inspiration for you, wherever you are in your breast/chestfeeding or pumping journey. 

Thank you to all of the parents who submitted their stories!  If after you read these memoirs you are inspired to submit your story, feel free to send it to RobinKaplan@sdbfc.com.    

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This Memoir is from Casey

Our breastfeeding journey began in June of 2018, following a traumatic (for me, fortunately not my son) childbirth. Combating an unexpected c-section, magnesium treatments, dehydration from blood loss, and significant tongue and lip ties with a macrosomic baby (11lb7oz) was a rough start. For about 5 weeks, I nursed my son with a shield, then immediately supplemented with pumped milk and formula, pumping almost as often as I was nursing him. I was recommended to see an IBCLC, and met with her a few weeks later, as well as regularly attending support groups one to two times a week. Our son had his lip and tongue ties revised, and we were able to immediately drop the shield and successfully latch FINALLY when he was about 6 weeks old. I attended support groups regularly, even once we established a solid latch and experienced success, to support others who were struggling with similar issues and for the camaraderie.

As we continued to nurse, my original goal of at least 1 year came and I had a choice to make. To conceive, my husband and I require IVF. While there are some unknowns and potential risks associated with nursing through infertility treatments, I consulted an IBCLC as well as professionals who research medication interactions with pregnancy and breastfeeding and decided the potential that the treatment wouldn’t work was worth the risk of continuing to nurse my son.

In July of 2019, we transferred an embryo and became pregnant with my second kiddo. My son nursed throughout the pregnancy, dry nursing when my supply diminished from typical pregnancy hormones, and continued as my colostrum came back in shortly after. I worked through some nursing aversion that arose from those same hormones. In March of this year, literally the same day that the state of California started a stay at home order, I went to the hospital to be induced. This was my first and only time away from my first nursling overnight, as my original plan of having him come in and snuggle with me and nurse was thwarted by the pandemic.  I gave birth to my daughter via c section on my second day at the hospital, and immediately began to nurse. She was much smaller than my son, only 7lbs1oz and had some temperature and blood sugar issues shortly following birth and wound up spending her first night in the NICU.  (I need to say that those long term NICU moms are the bravest women I’ve ever met, and many of them were pumping day and night to provide for their babies, even as their stay was stretched over several months.)

I traveled slowly to and from the NICU every couple hours to nurse my daughter, but her sugars needed a bit of support and we supplemented with formula after nursing those first few days.

After 5 days in the hospital, we finally got to go home and see my son. I wasn’t sure if he’d still be interested in nursing after 5 days with nothing, but as soon as I sat down at home, he instantly latched as if nothing had changed. I tandem nursed both my babies for the first time- my son at 21 months old, my daughter at 3 days old.

It’s been 4.5 months and both of my children still nurse well. I’m grateful that my daughter didn’t have any ties or other latching issues and was able to gain weight well. My new breastfeeding goal is as long as each of them want to nurse, though we have scaled back the frequency for my toddler, so that I have time to function throughout the day. He was thrilled when my full milk came back in!

I will forever be grateful to all of the IBCLCs for helping me salvage my breastfeeding relationship with my son and for continuing to support me and numerous other nursing parents to provide our children with the best start possible.

How Do I Wean from Supplementing my Breastfed Baby?

This is Part Two in our supplementation series.  Don’t miss Part One: I’m Told that my Breastfed Baby Needs to be Supplemented…. What Should I Do?

One of the most challenging aspects of supplementing your breastfed baby is knowing when and how you can reduce or completely stop that supplementation.  You will want to work with your pediatrician and an IBCLC to help fine tune this process for you and your baby, but here are some general guidelines.

The reason you were supplementing may determine when you can stop

Early supplementation in the first few days after your baby was born may have been recommended to help resolve a temporary medical situation, such as jaundice, hypoglycemia, or excessive weight loss.  Typically, once your milk supply has fully ‘come in’ and baby is gaining well, supplementation can stop. Longer-term supplementation, such as for a premature baby, baby with feeding challenges, or a breastfeeding parent working to increase milk supply, will likely require a longer weaning process.  In both cases, though, watching the baby for signs of effective breastfeeding will be an important part of baby's care.  

How do I know if my baby is breastfeeding well?

There are quite a few ways we can tell that a baby is breastfeeding well

• Baby actively feeds for 20-40 minutes, seems satisfied after eating, and can go about 2-3 hours between most feedings

• Breastfeeding is comfortable and your breasts feel softer after your baby has fed

• Diaper count - Babies in the first few weeks to months should pee/poop at least 5 times a day.  As babies mature, so do their digestive systems. After the first few months, babies often continue to pee at least 5 times daily, but poop frequency may drop to 1-2 times daily

• When you weigh your baby before and after a breastfeeding session (like with a gram-sensitive scale at a breastfeeding consultation or support group), your baby is taking in an appropriate amount for his/her age and weight.

• Weight gain - Baby is gaining the appropriate amount of weight based on his/her age  
  

What is the best way to wean from supplementing my breastfed baby?

As your baby begins to breastfeed more effectively and transfer more milk from you while breastfeeding, you might also notice that your baby begins to refuse supplements (or just takes less) after breastfeeding.  If your baby is gaining weight well, then you might consider offering less of a ‘top off’ after breastfeeding and see if your baby continues to gain weight well. If your baby is gaining more weight than expected for his/her age, this is also a reason to pull back on supplementation.

To wean from supplementing your baby, you will want to either reduce the amount of supplementation after each breastfeeding session or cut back on how often you supplement during the day.  Try this reduced supplement amount for a few days and see if your baby still seems satisfied after eating throughout the day and night, as well as check your baby’s weight to make sure he/she gained enough over that time period.  If weight gain is still more than needed/expected and your baby seems satisfied after eating, continue to pull back on the amount of supplement per day until you reach a point where you have either cut supplementing completely or dropped down to your baby’s sweet spot.

While reducing the supplementation amount, this also means that you might be able to cut back on the number of times you pump per day, which is what every parent wants to hear, right?  A lactation consultant can definitely guide you on this process so that your milk supply isn’t lowered with this decrease in pumping frequency.

What if I am unable to wean from supplementing my baby?

There are some situations when a breastfeeding parent may not have a full milk supply and will need to supplement long term.  Working with a lactation consultant can be very valuable during this process to help maximize your milk supply potential, as well as discuss options for long-term supplementation.  

It is incredibly important for any parent needing to provide long-term supplementation to understand that EVERY drop of breastmilk you produce for your child is valuable.  You are creating a perfect food for your child, as well as providing amazing immunity-boosting benefits that only YOU can create. Your milk was meant for your baby and breastfeeding does not have to be all or nothing.  While it can feel absolutely heartbreaking to hear that exclusive breastfeeding may not be a possibility, I’d like to share a beautifully written breastfeeding memoir on our website.  The author, Aran, brilliantly coins a new term, ‘Inclusive breastfeeding’, which helps put all of this breastfeeding and supplementation into perspective.

 So, what additional questions do you have about weaning your breastfed baby from supplements?  Feel free to add a comment here and we will gladly offer advice!

And, if you need some guidance on how to navigate your supplementation journey, book an appointment with us, as we would love to help!

To book an appointment at the San Diego Breastfeeding Center, click here!

If you don’t live in San Diego and would like to book a virtual consultation, email Robin at robinkaplan@sdbfc.com

If you are looking for a lactation consultant in your area, click here for ILCA’s Find a Lactation Consultant Directory

I'm Told that my Breastfed Baby Needs to be Supplemented.... What Should I Do?

Being told that your breastfed baby needs to be supplemented can feel extremely overwhelming and can often feel like quite a blow to the self-esteem.  You might be concerned about your milk supply and if your baby will prefer the bottle to your breast. You may feel confused as to why your baby isn’t gaining the appropriate amount of weight while breastfeeding.  

So, let’s talk about the reasons why a baby might need to be supplemented and how to do this without sabotaging your milk supply and your breastfeeding relationship.

What is a supplement?

A supplement is anything in addition to what your baby receives from your breast while breastfeeding.  Babies can be supplemented with: 

Mom’s own pumped milk (if baby is not removing her milk well enough)

Donor milk (from a milk bank or from another breastfeeding/pumping parent)

Formula

How do I know if my baby truly needs supplemental feedings?

Babies are expected to gain a certain amount of weight based on their age.  So, if a baby is NOT gaining that expected amount, additional supplementation is often recommended.  Here are the weight gain expectations for the first year of baby’s life:

Initial weight loss in the first few days of life - no more than 10% of baby’s birth weight

2 weeks - baby should be back to birth weight (or very close, if he/she lost more than 10% in the first 2 weeks

2 weeks - 4 months - baby should gain about 7 ounces per week

4 months - 6 months - baby should gain about 4-5 ounces per week

6 months - 1 year - baby should gain about 2-4 ounces per week

Why might a baby need to be supplemented?

There are many common reasons why a baby might need supplemental feedings.  

Some common medical issues that can arise shortly after birth that may lead to supplements are prematurity, low birth weight, poor feeding, low blood sugar levels (hypoglycemia), elevated bilirubin levels (jaundice), dehydration, excessive weight loss or poor weight gain.  After those first few weeks, some common reasons for supplementation are baby not removing milk well while breastfeeding (due to tongue tie, reflux, very long feeding sessions) and a low milk supply. In all of these cases, the first step is to ensure that baby is breastfeeding effectively.  Next we want to assess mom’s milk supply to make sure that she is producing enough milk for her baby. Sometimes all it takes are a few modifications to the baby’s feeding routine to help baby start to gain weight. Other times it requires a lactation consultation (done by an IBCLC) to assess baby’s feeding and mom’s milk supply for the cause for baby’s low weight gain.

What if I can't express enough milk for my baby?

First you’ll want to make sure that you have everything you need to express your milk.  If using an electric pump, make sure the pump flanges fit correctly and that you are pumping for about 15 minutes after breastfeeding.  Some moms let down for the pump easily. Others find that they prefer a hand pump or hand expression. You will want to find what works best for you.

In those first few days after birth (when milk production has not quite yet surged), it can be a bit challenging to express a measurable amount of milk.  In this case, sometimes baby might need to be supplemented by donor milk or formula.

Once your mature milk is in (after those first few days), you might want to meet with an IBCLC to put together a breastfeeding/pumping plan to see if you are able to express enough milk for your baby, as well as increase your milk supply, if necessary.  If you are not yet able to express enough milk for your baby’s supplemental feedings, donor milk or formula would be recommended.  

Do I have to use a bottle when giving my baby supplemental feedings?

Not at all!  There are several ways to supplement a baby.  Each way has its pros/cons and will be determined by what works best for you and your baby.

Cup feeding is great for older babies, as well as some younger babies who will not take a bottle

Finger feeding is great for the first few weeks of life, as the flow is slow and your finger can help organize your baby’s sucking rhythm.

Supplemental nursing systems (SNS) allow your baby to be supplemented at the breast so that he/she still thinks everything is coming from you!  The SNS has a tube that slips into your baby’s mouth, at the breast, to provide the supplement at the same time baby is breastfeeding. This works best when baby is latching/breastfeeding well and mom is trying to increase her milk supply.

Bottles are definitely an option, as well.  You will want to offer a bottle in a baby-led (paced) manner so that your baby doesn’t begin to prefer the ease and flow of the bottle, compared to your breast.

Will my baby ever be able to fully breastfeed after supplements?

Generally, the answer to this is YES!  Most reasons for supplementation are short-term problems that are resolved relatively quickly with good treatment.  Premature babies grow and get stronger, and typically get better at breastfeeding around their due dates or shortly after.  A baby who is having difficulty with breastfeeding immediately after birth will often be ready for breastfeeding within a few days after birth.  If breastfeeding challenges linger for more than a few days, an IBCLC can help identify the reasons and set you on a path for reducing and hopefully eliminating supplementation as soon as possible. In the meantime, expressing your milk in addition to breastfeeding will help maintain and build your milk supply as challenges resolve.  

When can I stop supplementing?

Part 2 will discuss how you’ll know it's time to wean from supplements and helpful tips for doing so. 

For more information about supplementation reasons, methods, and choices, check out these The Boob Group podcast episodes: 

Exclusive Breastfeeding and Early Supplementation 

Breastfeeding the Jaundiced Baby

When Breastfeeding Doesn’t Go As Planned 

Low Milk Supply: Donor Milk, Milk Banks, and Formula

Partial Breastfeeding: When Supplements are Needed

5 Breastfeeding Myths and Misconceptions that Really Annoy the Heck Out of Us!

How many times have you heard a so-called breastfeeding ‘fact’ from a family member, friend, healthcare professional, or online resource that has your ‘mama-radar’ going off at warp speed?  Maybe something just doesn’t sound right. Maybe it goes against all of your breastfeeding instincts. Maybe it is completely contradictory to what you heard the previous day. Well, it’s time to start busting those myths and misconceptions! 

World Breastfeeding Week 2019 begins in a few days and this year’s theme is all about empowering breastfeeding families.  We couldn’t think of a better way to empower breastfeeding families than by providing real facts to some of the most common breastfeeding myths/misconceptions! We will also be chatting about additional breastfeeding misconceptions on Baby Tula’s Facebook Live on August 2, 2019 at 10am PST, so definitely join us that day!

So, here we go…..

Myth #1: When pregnant, you should rough up your nipples to prepare them for breastfeeding.

Ok, so who thought up this ridiculous idea??? Why would we ever think that "roughing up" our nipples by rubbing them with a towel was a good recommendation. There is no need to cause nipple trauma and scabbing before your baby even arrives! In fact, rubbing your nipples can actually remove the protective substances produced by the breast during pregnancy and afterwards. Sure, your nipples may feel sensitive for those first few days to weeks, but with a great latch, they will become less sensitive over time, all on their own. No need to do anything to prepare them prior to your baby being born.

Myth #2: If your baby feeds more than every 2-3 hours, then he/she is not getting enough.

So, this statement is a little complicated.  Sometimes, this can be true, especially if your baby is not gaining weight well and feeding every hour throughout the day and night.  This situation might indicate that your baby might not be getting enough milk and your milk supply/baby milk transfer should be assessed.

Typical baby behavior is feeding about 8-12 times per 24 hours, especially for the first few months.  Remember, babies’ tummies are small, so they need frequent, small feedings. Some babies with reflux and tummy issues also like small, frequent feedings.  There are also situations where babies temporarily feed more frequently, like during cluster feedings times (aka witching hours) and during growth spurts (which last a few days.)  Cluster feeding often happens when your baby needs a bit more snuggling time to unwind from the day and growth spurts are nature’s way of requesting more milk for future feedings. So, these are totally normal situations when a baby would feed more frequently than every 2-3 hours and don’t indicate a low supply, at all.

Myth #3: Nursing beyond a year is just for mom’s benefit

So, let’s just think about this one for a second.  Is there an on/off switch that makes breastmilk less valuable and nutritious on a baby’s first birthday?  Does it suddenly lose all of its immunological properties? I think not. In fact, there are so many nutritional, social, mental, and physical benefits for breastfeeding beyond a year, as well as the fact that breastfeeding beyond a year is normal.  Kellymom.com has incredible resources on this subject, so I will just share a few of my favorites:

• According to Dewey (2001), in the second year (12-23 months), 448 mL of breastmilk provides:

  • 29% of energy requirements

  • 43% of protein requirements

  • 36% of calcium requirements

  • 75% of vitamin A requirements

  • 76% of folate requirements

  • 94% of vitamin B12 requirements

  • 60% of vitamin C requirements

• Immunities in mother’s milk continues as long as breastfeeding continues and some increase in concentration as the child gets older.

• The American Academy of Pediatrics recommends that “Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child… Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother… There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.” (AAP 2012, AAP 2005)

So, if you want to breastfeed for longer than a year, go for it!  It is fantastic for both you and your child. What’s most important is the breastfeeding family’s goals for how long they want to breastfeed…. Not what others believe should be the goal!

Myth #4: Small breasts = small milk supply; Large breasts = large milk supply

As a lactation consultant, I see breasts of all shapes and sizes and this misconception could not be further from the truth. Milk supply is determined by the amount of glandular tissue you have in your breasts and how this fatty tissue expands and multiplies during pregnancy and after your baby is born. Milk supply also significantly depends on breast emptying after your baby is born…. The more you empty your breasts when feeding or pumping, the more signals are sent to your brain to produce more milk. The actual breast is just the vessel/container to hold the milk. So, a size DD breast can hold more milk at one time, compared to a size B breast, but may not necessarily differ in the amount of milk made over a 24 hour period.

Myth #5: If your baby is taking forever to transfer milk while breastfeeding, then you have a lazy baby

I don’t think there are many phrases I despise more than ‘lazy baby.’ Think about this…. Why would a baby choose to be lazy? Your baby’s only job is to feed to stay alive, therefore survival is based on being as robust a feeder possible. A baby who seems ‘lazy’ and takes over an hour (on average) to breastfeed is actually a baby having a difficult time breastfeeding. This could be caused by tethered oral tissue (tongue/lip tie), jaundice, using a nipple shield, prematurity, as well as many other reasons. So, babies who appear ‘lazy’ are often just doing the best that they can with the situation they’ve been dealt. And this is a fantastic reason to meet with an IBCLC to see how you can help your baby begin to feed more effectively and easily, as soon as possible!

So, what other breastfeeding myths and misconceptions absolutely drive you crazy?

Share them in the comments and we will do our best to remedy this misinformation in our interview on Baby Tula’s Facebook Live this week.

Are Tongue and Lip Ties Being Overdiagnosed and Overtreated?

Written by Robin Kaplan, M.Ed, IBCLC, Owner of San Diego Breastfeeding Center

That has been the million dollar question of the week.  Since Rachel Cautero published her article in the Atlantic last week about this topic, conversations about tethered oral tissue (TOTs) have had a resurgence of epic proportion.  To discuss this topic, I was interviewed by Meghna Chakrabarti on NPR’s On Point this week. Her interview, entitled To Improve Breastfeeding, Babies Get Their Tongues Clipped.  Is it necessary?, included the Atlantic journalist (Rachel Cautero), a pediatric ENT from John Hopkins (Dr. Jonathan Walsh), and me, an IBCLC from San Diego.  

I encourage you to listen to this interview, as there were many important issues brought up that parents need to hear.  I also encourage you to consider listening through an unbiased lens, as the first 30 minutes are fairly skewed due to the sharing of personal breastfeeding experiences by Meghna and Rachel.  They talk about being informed of their infants’ tongue ties during a very vulnerable early postpartum period and how upsetting this information was to them. They shared how they both decided to stick with breastfeeding, despite significant pain for weeks and months, instead of considering a tongue tie release.  And they both ended up finding that breastfeeding eventually got better and that they felt frustrated with all of the discussions online about tongue tie and upper lip tie releases, which they feel is being sold as the ‘cure-all’ to lactation woes.

Keep in mind….these are just two individuals’ stories out of many.  We all have our personal stories of parenthood/breastfeeding/labor, etc that skew the way we view a situation because they evoke an emotional response in us.  These emotional reactions are normal, but are that person’s point of view.

What I would like to share are the most pertinent points about tethered oral tissue (TOTs) that were shared in this interview, as well as a few more that weren’t shared due to time constraints.

4 Main Take-Aways about Tethered Oral Tissue (TOTs)

Tethered oral tissue can restrict range of motion in the tongue, lips, and cheeks

• All people have frenulums, but to have tethered oral tissue (TOTs) means that the frenulum is restricting range of motion and impacting function.  Here is a handout that includes many of the symptoms that can be related to TOTs.

• These TOTs do not stretch over time, but some children/adults learn to compensate despite the tightness.  This is why some children and adults don’t show or feel that they have long-term complications.

• Releasing restricted frenula can have a profoundly positive effect on both parent and baby and their ability to meet their breastfeeding goals, but is not always necessary.

International Board Certified Lactation Consultants (IBCLCs) identify tethered oral tissue at a higher rate than pediatricians/ENTs because they are the professionals completing full oral/feeding assessments.  

• IBCLC assessments are not 15 minute well-baby checks.  They are extensive assessments, lasting 1-3 hours, using research-supported evaluation tools.  

• TOTs cannot be evaluated just by looking in the mouth or at a photo of the mouth, tongue, and lip.  Function must be taken into account.

• Parents should be walked through each part of the oral/feeding assessment so that they can make an informed decision about what is best for their child.

• It is always necessary to go back to basics (positioning and latch) first, before blaming a tongue or lip tie. If the symptoms for the breastfeeding parent or baby are not relieved with the basics, then further assessment is necessary.

• Parents should be presented with a menu of options: bodywork (CST/PT/OT/Chiro, etc); oral exercises; tummy time; supplementing; exclusive pumping, etc. - everyone deserves to be supported regardless of their decisions.

There has been an increase of identification of and recommendation to release tethered oral tissue in the past two decades, with good reason

• Increased research and ultrasound investigation on how the tongue and lips function while feeding have shown what is necessary to achieve comfortable, effective breastfeeding and milk removal.  This information was not available until the past two decades.

• There has been a shift in the international culture to be more pro-breastfeeding than it was during the 1900s.  It is unfortunate that some families feel ‘pressured to breastfeed’, as Rachel mentioned in the interview. Personally, I think this shift in societal views towards breastfeeding has more to do with current research identifying the vast health-promoting and immunological benefits to mom and baby when breastfeeding, rather than parents feeling pressured to breastfeed.

• TOTs are nothing new.  Tongue ties and frenotomy descriptions can be found in early Japanese writings, other historical documents, and even the bible.  In the 1600s, frenotomy was widely known and there is documentation that describes that midwives would keep one fingernail long and sharp so that she could release the tight frenulum without the use of an instrument.

• In the early 1900s, formula was advertised as better than breastmilk and breastfeeding was considered as something that only impoverished people do.  Up until then, if a mother could not breastfeed her baby, the family hired a wet nurse or the baby would die due to lack of nourishment. Formula changed the way we looked at infant nutrition and breastfeeding, which meant tethered oral tissue wasn’t viewed as important to address.  With this pendulum shift to positive views about breastfeeding, parents want answers when challenges arise. And many of these challenges can be attributed to TOTs.

There is a lack of evidence specifically studying the long term effects of tethered oral tissue (TOTs)

• There are several case studies and randomized control studies on how frenotomies improve breastfeeding outcome.

• There are some correlations between TOTs and challenges eating solid foods, speech and change in oral/dental structure, but there is only a small amount of research to back this up.   We clearly need more research.

• What we do know is that children with TOTs often mouth breathe, which is widely recognized as pathological and may lead to:

  • open-mouth posture, which can block the airway when sleeping, leading to bruxism, snoring, sleep apnea

  • impaired swallowing, which can lead to a palate that doesn’t naturally expand and Eustchian tubes not opening and equalizing pressure in the middle ear

So, what’s the overall take away message?

When a family has breastfeeding challenges and doesn’t receive a comprehensive oral/feeding assessment that evaluates tongue and lip function, then we run the risk of tongue/lip ties being overdiagnosed and overtreated.   

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For more information about tethered oral tissue, check out these resources:

Dr. Ghaheri’s website

SOS for TOTs by Lawrence Kotlow, DDS

Tongue-Tied by Richard Baxter, DMD, MS

Kellymom: Breastfeeding a Baby with a Tongue Tie or Lip Tie (Resources)

Tongue tie articles on SDBFC’s website