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What Can I Do About My Low Milk Supply? May 09, 2014 13:07

Written By Michelle Roth, BA, LCCE, IBCLC

One of the top reasons women wean their babies before intending is thinking that their milk supplies are low (McCarter‐Spaulding & Kearney 2001; Gatti 2008; Kent, Prime & Garbin 2012; Kent, et. al. 2013; Neifert & Bunik 2013). While there are cases where women cannot produce enough milk for their babies, more often the problem is in expectations about breastfeeding patterns and what’s normal for a breastfed baby.

Sometimes around 10 days and then again around the 4-6 week mark, women think they have “lost their milk” because their breasts don’t feel as full or their milk is no longer leaking copiously. Changes around these times, however, are normal fluctuations in the way your body makes milk. They are likely signs that your initial engorgement has subsided and your milk supply has evened out to perfectly match your baby’s needs (Mohrbacher 2010; Kent, et. al. 2013).

Women who feel their milk supply is insufficient often base this perception on infant behavior – a baby who seems unsatisfied, who wants to nurse often, who is fussy or unsettled, etc. Though these behaviors can have many causes, women tend to blame their own bodies for not producing enough milk (Mohrbacher 2010). In addition, use of formula before hospital discharge is often wrongly instituted for “insufficient milk supply” at a time when moms aren’t yet making much milk (as nature intended!). While their bodies are, in fact, working right, they are led to believe something is wrong. And this perception sticks with them causing them to wean early (Gatti 2008). In addition, McCarter-Spaulding and Kearney (2001) found “mothers who perceive that they have the skills and competence to parent a young infant also perceive that they have an adequate breast milk supply” and vice versa. If a mom isn’t confident in her abilities, she may think her milk supply is low whether that’s truly the case or not.

So, milk supply issues – whether real or perceived - can impact how long a baby is breastfed. The solution is to help these moms feel confident in their milk supply. Working to increase milk supply will help those who are truly experiencing a dip in output, and may aid those who perceive a low supply feel more self-assured in their ability to breastfeed. Consider these tips for increasing milk supply:

  • Nurse more! The more stimulation your breasts get, the more milk you will make. And the baby is better at prompting this than any pump on the market. You need to be sure, however, that your baby is transferring milk well. Do you hear your baby swallowing after every one or two sucks early in the feeding and less frequently as the feeding progresses? This may sound like a soft “kah” sound, or may look like a pause in the middle of a suck. Do your breasts feel full before a feeding and softer when your baby has finished? These are good signs that your baby is transferring milk. Is your baby falling asleep at the breast soon after starting a feeding? These babies need to be encouraged to keep going.

Newborns will nurse every 1-2 hours, but even older babies may nurse often. Has your baby stopped nursing so often? Is he skipping feedings? Are you getting busy during the day or using a pacifier and missing some feeding cues? Has your baby started “sleeping through the night”? These can all lead to a decrease in supply. Try a “nursing vacation” – spend the weekend tucked in bed with your baby and nurse as often as possible.

  • Pump: Using a quality electric breast pump can help to stimulate supply. Keep in mind that pumps and pumping supplies can wear over time, so be sure yours is in top shape for the best results. Also, some brands are better than others at removing milk, so do some research before purchasing a pump.

Some women choose a few times a day, and consistently pump at those times. Other moms pump on one side while baby nurses on the other. Or you can try pumping for 5-10 minutes after every nursing session. The key to getting a good yield of milk when pumping is the ability to elicit milk ejections. If you have difficulty letting-down to a pump, you will get less milk. Two let-downs are sufficient, and three or four are even better. (Mohrbacher 2010). Use all of your best relaxation techniques: relax your muscles, breathe deeply, think about your baby, listen to a recording of your baby crying, smell something baby has slept in, do whatever it takes to condition yourself to let-down to the pump.

Also, doing breast massage before and during a pumping session (sometimes called “hands-on pumping”) can increase the amount of milk you are able to remove, and may give your nerves more stimulation resulting in an increase in production (Mohrbacher 2012).

  • Consider herbal galactagogues: A galactagogue is a substance that can increase production of breastmilk. Different substances have different mechanisms, but they should all be used in conjunction with increased nursing or pumping, or reserved for use until after other methods have failed to produce the desired results (Mohrbacher 2010).

Fenugreek (Trigonella foenum-graecum L.) is an herb used in many cultures to increase milk supply. The recommended dosage is 1800mg three times a day. Supply generally increases 24-72 hours of beginning the supplement; but for some women, it can take as long as one to two weeks. Use caution with this supplement if you have a history of allergies, asthma, hypoglycemia, or diabetes, and do not use if you are taking blood-thinning medications.

The effects of fenugreek are improved when combined with the herb blessed thistle (Cnicus benedictus). Adding 3 capsules of blessed thistle 3 times per day along with fenugreek improve output.

Both fenugreek and blessed thistle seem to be the most effective if used in the first few weeks after birth. Other herbs (including marshmallow root, goat’s rue, alfalfa, fennel, spirulina, raspberry leaf, brewer’s yeast, and shatavari) and some foods (for instance, oatmeal) have milk-enhancing properties, so adding them to your diet may boost your milk production. Keep in mind, though, these substances won’t do much if you aren’t nursing or pumping often.

  • Discuss medications with your healthcare provider: Prescription medications that act as galactagogues are sometimes warranted when all else has failed. Domperidone is the medication most likely to be effective in increasing milk supply, and the least likely to cause untoward effects for mom or baby. It has been used successfully in many parts of the world; however, use in the US is restricted. Reglan (metoclopramide) is another drug that helps to increase milk production. This drug should not be used by anyone with a history of depression or anxiety as it can increase the severity of these symptoms, and can even cause these symptoms in someone without a prior history. Use of Reglan should be considered with caution (Mohrbacher 2010; Zuppa 2010).


Any time you are dealing with a dip in supply, you should consider working with someone knowledgeable about breastfeeding, such as a board certified lactation consultant (IBCLC) or trained peer counselor. Sometimes just having that support is all you need to persevere through difficulties with supply. Any amount of breastmilk your baby gets is a gift – but maximizing your production so you can continue to nurse is well worth the effort, for you and for your baby.

 

References:

Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship, 40(4), 355-363.

Kent JC, Hepworth AR, Sherriff JL, Cox DB, Mitoulas LR, Hartmann PE. (2013). Longitudinal Changes in Breastfeeding Patterns from 1 to 6 Months of Lactation. Breastfeeding Medicine 8(4), 401-7

Kent, J. C., Prime, D. K., & Garbin, C. P. (2012). Principles for maintaining or increasing breast milk production. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(1), 114-121.

McCarter‐Spaulding, D. E., & Kearney, M. H. (2001). Parenting Self‐Efficacy and Perception of Insufficient Breast Milk. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 30(5), 515-522.

Mohrbacher, N. (2012). To Pump More Milk, Use Hands-On Pumping. http://www.nancymohrbacher.com/blog/2012/6/27/to-pump-more-milk-use-hands-on-pumping.html [Accessed March 30, 2014].

Mohrbacher, N. (2010). Breastfeeding Answers Made Simple. Amarillo, TX: Hale.

Neifert M & Bunik M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60(1), 115-145.

 

Zuppa, A. A., Sindico, P., Orchi, C., Carducci, C., Cardiello, V., Catenazzi, P., ... & Catenazzi, P. (2010). Safety and efficacy of galactogogues: substances that induce, maintain and increase breast milk production. Journal of Pharmacy & Pharmaceutical Sciences, 13(2), 162-174.


Can a birth doula improve breastfeeding success? March 29, 2014 15:26

Written By Michelle Roth, BA, LCCE, IBCLC

Continuous labor support during childbirth has many advantages, including a decreased risk of interventions (including cesarean birth), less use of pain medication, and more positive birth memories (Hodnett 2013). But did you know a doula may also increase breastfeeding success?

From the Greek word for slave, doula has evolved to mean a woman who supports another woman during the birth process. During childbirth, she supports the laboring woman and her partner physically - helping mom change positions, providing massage or counterpressure, and giving the birth partner suggestions on how to help – as well as emotionally and intellectually. She is typically with the couple from the start of labor to the time of birth. Because of her presence and her trusted position with the new parents, she may be the ideal member of the birth team to help a mom initiate breastfeeding.


In an early study of the effect of doula care on breastfeeding success, researchers found that women in the intervention group (doula care) were more likely to be exclusively breastfeeding at one month after the birth (Langer et al, 1998). These women were also less likely to wean or supplement for perceived low milk supply. In closing, the researchers write, “These results provide grounds to consider that psychosocial support during labour and the immediate postpartum period should be part of comprehensive strategies to promote breastfeeding “ (1062).

In another study, Nommsen-Rivers and colleagues (2009) assessed the timing of the onset of lactation and the proportion of breastfeeding moms at 6 weeks postpartum for two groups – those with and without doula care for the birth. Compared to the standard care group, women in the doula care group were more likely to have their milk come in by day 3, were less likely to use a pacifier in hospital, were less likely to report concerns about milk supply, and were more likely to be breastfeeding at 6 weeks. After looking at relationships between confounding factors, the authors conclude, “Among mothers with a prenatal stressor, doula care was particularly effective in increasing the odds of continued breastfeeding” (172).

When studying the effectiveness of a hospital-based doula program, Mottl-Santiago and colleagues found that women with doula care were more likely to express an intention to breastfeeding, and were significantly more likely to breastfeed within the first hour after birth. The authors caution, however, that their results may not be a direct effect of a doula at the birth, since the doulas also provided prenatal breastfeeding education to the expectant mothers.

A recent study showed even more promising results. Of the women who had doula care during birth, nearly all initiated breastfeeding (97.9% compared to 80.8% in the general low-income population studied). When looking at a subgroup of women who are less likely to initiate breastfeeding, the researchers found 92.7% of African American women with doula support initiated breastfeeding, significantly higher than in the general population studied (Kozhimannil 2013). The authors suggest that “access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation,” with the key being suitable matching of doulas to the client population.

What more evidence do we need? Having doula support for your labor and birth may increase the chances of your breastfeeding. Choose a doula who shares your same values and birth philosophy so you feel comfortable and confident in her care. Ask friends, family, your care provider, or your childbirth educator for referrals or check the DONA International website for a doula in your community. Be sure to interview the doula you choose – even asking about her background in breastfeeding education and support. Let her know you plan to nurse your baby, and ask if she will help you get started. Her support may be essential.

 

References:

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7.

Kozhimannil KB, Attanasio LB, Hardeman RR, O'Brien M. (2013). Doula care supports near-universal breastfeeding initiation among diverse, low-income women. Journal of Midwifery & Women’s Health. E-pub ahead of print 9 JUL 2013.

Langer A, Campero L, Garcia C, Reynoso S. (1998). Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial. British Journal of Obstetrics and Gynaecology (105), 1056-1063.

Mottl-Santiago J, Walker C, Ewan J, Vragovic O, Winder S, Stubblefield P. (2008). A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Matern Child Health J 12, 372–377.

Nommsen-Rivers LA, Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. JOGNN 38, 157-173.

 


The Power of Prolactin: Reverse Cycling and Your Milk Supply February 13, 2014 15:16

Written By Michelle Roth, BA, LCCE, IBCLC

Prolactin is a hormone produced by the pituitary gland in both males and females throughout the life cycle. It’s a protein important for immune function, cell growth, and more. In females, prolactin takes a starring role in the reproductive cycle, and is especially important as the main hormone of milk production.

 

 

Often called “the mothering hormone,” prolactin creates protective behavior in a woman during the birth process, as well as throughout breastfeeding. One of the
most interesting aspects of this substance is that it has a circadian rhythm – higher levels are present at night in both males and females. This diurnal pattern may be the reason women who practice unrestricted breastfeeding – both day and night – tend to see a delay in the resumption of their menstrual cycle as well as a stronger milk supply.

Building a robust milk supply depends on frequent nursing from the start. In fact, nursing often establishes more prolactin receptors in the breast, increasing a mom’s ability to make milk over the entire cycle of lactation. And the more often you nurse, the better your supply – thanks to an intricate hormonal dance that includes prolactin, among others. A full breast will release a feedback hormone that says, “hey, stop making milk.” But a breast that is emptied often keeps filling. Prolactin levels rise whenever a baby suckles - they spike during nursing - and more prolactin equals more milk production.

For moms struggling with milk supply issues, nursing more frequently is often all that’s needed for improvement. But this increase in nursing needs to happen at night, too, in order to take full advantage of the higher nighttime prolactin levels. Sometimes babies naturally get into a pattern of more frequent night nursing, often called reverse cycling. These babies nurse more in the evening and at night, and less during the day for a variety of reasons. While moms may be losing some sleep, reverse cycling is actually a boost for their milk supplies.

Reverse cycling is most likely to happen in situations where mom and baby are apart during the day, but together at night (for instance, when a mom works outside the home). Sometimes a working mom will find that her baby drinks only enough during the day to take the edge off his hunger, but then spends the evening nursing non-stop and wakes several times throughout the night to nurse. This pattern shows a strong mother-baby attachment. Rather than a behavior in need of correction, it is, in fact, the key to keeping up a strong milk supply after returning to work. 

But reverse cycling can happen for other reasons, as well. If you are taking care of other children, or have simply had a busy day for whatever reason, it may be that you miss some of the daytime cues for breastfeeding. Your baby may try to catch up – on calories and on closeness - by reverse cycling. Or maybe your baby is at that distractible stage – every time he nurses, he starts and stops multiple times to look at the cat, listen to the noises outside, smile at his sibling, etc. Or maybe he’s busy learning to crawl or walk, and doesn’t want to slow down to nurse. These babies may use the quiet of night to get the majority of their calories.

You might think that all that night waking is a disadvantage, and others may encourage you to get your baby onto a “sleep schedule.” But, research shows moms whose babies nurse often at night actually get the rest they need. This is especially true if you choose to co-sleep with your baby. Moms and babies who sleep in close proximity – especially when sharing a bed – tend to have entrained sleep cycles. When your baby wakes, you’re in the same stage of sleep, and the waking doesn’t provide the same level of disruption to your system that sleeping apart in separate rooms would. When a mom sleeps near her baby, she often notices small sounds and movements before either she or her baby are fully awake, and can often doze as baby nurses. If you choose to share a bed with your baby, be sure that you take precautions to make your sleep space safe. Learn more here [Add hyperlink - http://cosleeping.nd.edu/safe-co-sleeping-guidelines/]. If your baby is reverse cycling and you’re feeling a little sleep deprived, try going to bed earlier or napping during the day.

Another benefit of reverse cycling for working moms is that they may not need to pump during their workday. If your caregiver tells you repeatedly that your baby isn’t taking much from his bottles, but he nurses like crazy when you’re together, you may be able to cut back on how often you pump (or maybe not even pump at all depending on your baby’s pattern). Many women find this eliminates much of the stress surrounding working and breastfeeding. You can read more about other working moms’ experiences with reverse cycling and nighttime nursing in La Leche League International’s magazine for mothers, New Beginnings here  [http://www.llli.org/nb/nbmayjun00p98.html] and here [http://www.llli.org/nb/nbiss3-09p32.html].

The biggest benefit of reverse cycling, though, is that the baby consumes more breastmilk, thus keeping your milk supply strong and your baby healthy and happy. The key is to practice unrestricted breastfeeding when you are with your baby – whether that feeding takes place day or night - to take advantage of your hormones for keeping up your supply.

 

About the author

Michelle Roth, BA, LCCE, IBCLC is a board-certified lactation consultant working in a private pediatric practice. She has been a La Leche League Leader for the past 12 years, and currently serves on the Area Council for LLL of Western PA. As a freelance writer and editor, her favorite jobs are proofreading and blog writing. With 4 active children, she doesn’t get much time to herself; when she does, she enjoys reading, crocheting and cross-stitch.

 

Resources:

Ayden, KK. (2001). Employed Mothers: Supporting Breastfeeding and Mother-Baby Attachment. Leaven 37(5), 101.

Bonyata, K. (2011) Reverse cycling. Accessed at http://kellymom.com/bf/normal/reverse-cycling/.

Buckley, S. (2010) Ecstatic Birth – Nature’s hormonal blueprint for labor. E-book. Available at www.sarahbuckley.com.

Lawrence RA & Lawrence RM. (1999). Breastfeeding: A guide for the medical professional. 5th ed. St. Louis, MO: Mosby.

Riordan J & Wambach K. (2010). Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett.

West D & Marasco L. (2009). The Breastfeeding Mother’s Guide to Making More Milk

ACUPUNCTURE: An Ancient Practice for Breastfeeding Health November 13, 2013 20:10

You may know someone who has treated their migraines or muscle pain with acupuncture, but did you also know that this ancient Traditional Chinese Medical practice is also effective in treating common breastfeeding complications and increasing milk supply?

WHAT IS ACUPUNCTURE, EXACTLY?

Acupuncture is a five thousand year old practice that, combined with herbal treatments, massage, nutrition, and other various practices, forms the wider umbrella of Traditional Chinese Medicine (TCM).  TCM approaches the body as a vessel full of vital energy.  This energy flows throughout the body on a system of meridians.  This energy is called chi (qi).  The premise is that when your chi is off balance or blocked, your body can experience all kinds of pain and illness. Through acupuncture, these maladies are alleviated or eliminated by manipulating (or stimulating) specific meridian points associated with the flow or balance of energy.

When you undergo acupuncture, an experienced practitioner will place very fine needles into meridian points directly connected to the energy blockage.  You might feel a slight twinge of pain as the needle goes in, or you could feel nothing at all.  Once the needles are placed and wiggled a bit, you’ll get to rest quietly for fifteen minutes to an hour.  You may even fall asleep!  (The nap alone sounds good, right?)  The needles are then painlessly removed and you’re on your way to wellness!  Many women experience increased milk production and a decrease of symptoms of mastitis after just one visit, but it may take more depending on your particular condition.

From a western medicine mindset, this can be a little bit hard to stomach.  It may help to know that in 1997, the National Institute of Health (NIH) gave their nod of approval for the use of acupuncture for the treatment of various conditions, with promise of future widespread approval.  According to NIH’s National Center for Complementary and Alternative Medicine (NCCAM), the number of adults using acupuncture in the U.S. has increased by over a million since then.

WHY DOES ACUPUNTURE HELP WITH BREASTFEEDING?

According to Monica Legatt M.Ac., Dipl., NCCA, of Downtown Seattle Acupuncture, typical problems with lactation are a result of either insufficient energy or stagnant energy. 

When you don’t have enough energy, you will often experience low milk production. It is fairly common for a new mother to be exhausted post-partum.  Combine that with blood loss during delivery, and the levels of energy and blood flow necessary to produce sufficient milk are just not there.  Acupuncture treatment actually increases the hormones necessary to produce and move breast milk.  In TCM, your practitioner will combine diet recommendations with herbal treatments and acupuncture to achieve a healthy milk supply for your nursing infant.

When your energy isn’t flowing properly around the breasts, you may experience engorgement, pain and pressure, distention, and even mastitis (which also involves infection).  This energy blockage generally stems from emotional stress such as anxiety, depression, resentment, anger, frustration, or any of the other day-to-day stresses you may feel as a new mother.  These stresses cause a blockage in the flow of energy within the liver channel, which is related to nipple function in women and thus breast milk production and nursing.  Aside from avoiding all stress (yeah, right), acupuncture can open up the energy blockages causes the painful symptoms.

When you receive acupuncture to treat these symptoms, you can rest assured that there will be no needles inserted into your breast!  The practitioner will be treating the liver channel, which has points near the rib cage and on the torso, legs, and feet.

The best way to treat mastitis is by combining western medicine (antibiotics) to get rid of the infection, and acupuncture along with other TCM therapies to relieve the blockage.

 

 

 

 

 


HOW DO I FIND A GOOD ACUPUNCTURIST?

 

 

The first thing to do is to ask your best resource… your friends!  A first-hand recommendation for a good acupuncturist who has worked well with lactation issues beats any search engine you can put your curser on.  Ask at your mom’s group.  Ask your lactation consultant, doula, or midwife.  Ask your doctor.  Once you get a small list of recommended practitioners, do your homework.

Check the acupuncturist’s credentials.  There are several certifying bodies that train TCM practitioners in proper technique, and you’ll want a string of letters behind their name to ensure that you’re getting the highest quality treatment. 

MD or DO:  Your practitioner is a certified medical doctor, but ask if he or she has their Medical Acupuncture Certification through the American Board of Medical Acupuncture.

MAc, or M.A.O.M.:  Masters in Acupuncture and Oriental Medicine.  Your practitioner has completed a rigorous program through the Accreditation Commission for Acupuncture and Oriental Medicine.

NCAA, or NCAAOM:  A certificate from the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is required to obtain a state license to practice acupuncture.

Finally, you may want to check with your insurance company to see if acupuncture is covered.  If it is, ask your provider if any practitioners on your list are within your network and if their services are covered.

As you embark on this new path to nursing health, please remember that unless an acupuncturist is also a certified doctor, they are not in a position to diagnose medical conditions.  It’s best to always get a diagnosis from your doctor or midwife and then ask him or her if acupuncture would be beneficial to a holistic treatment plan. 

RESOURCES:

http://blog.seattleacupuncture.com/acupuncture-for-lactation-milk-supply

http://motherloveblog.com/tag/acupuncture-and-breastfeeding/

http://umm.edu/health/medical/altmed/treatment/acupuncture

http://www.acupuncture.com/education/points/liver/liver_index.htm

http://www.nih.gov/news/pr/nov97/od-05.htm

http://nccam.nih.gov/health/acupuncture/introduction.htm

http://acupuncturists.healthprofs.com/cam/content/acupuncture_credentials.html