Breastfeeding a Baby with Lip and Posterior Tongue Ties

Today I have a guest post from a mom, Diane Coombs of New Foundland, Canada, who shares her story on breastfeeding a baby with lip and tongue tie.

My baby girl is nine months old today! Our breastfeeding relationship got off to a rough start because of an undiagnosed posterior tongue tie and lip tie. The pediatrician in the hospital did not diagnose her, neither did our LC nor family doctor. I was told over and over it was 'poor latch' or thrush or 'lazy feeder.' All were incorrect.

Scarlett was gagging, coughing, extremely gassy, and she 'clicked' with each suck, my poor nipples were being crushed and so badly abraded my daughter would spit up blood after feeding. Nursing was making her so tired, she was sleeping through feeds to conserve calories, and was losing weight in a vicious cycle.

I researched what could be causing our issues, trusting my gut that there was something more wrong besides the diagnosis given. I went to a LLL meeting and met a mom whose story matched mine. She was unable to get her son treated locally so she went to see Dr. Kotlow, a pediatric dentist in Albany, NY - the leading expert in the field of tongue and lip tie. Immediately I got in touch with Dr. Kotlow. He diagnosed the problem via pictures I sent him, and I quickly booked our flight: 1500 miles from Eastern Canada to Albany. She was treated (laser revision) and immediately, she latched PERFECTLY!

I am not saying each baby with latch issues is tongue or lip tied, (and not every baby with a lip and/or tongue tie has trouble breastfeeding) but if you are having problems, and seem to have no answers - research it and see if tongue tie (especially POSTERIOR tongue tie) and/or lip tie is the issue. Here are some places to start:

The Hidden Causes of Feeding Problems?

Posterior Tongue Tie Information

Diagnosing Tongue-Tie in a Breastfed Baby: Tight frenulum can cause painful breastfeeding and poor weight gain

Dr. Kotlow Articles on lip/tongue tie 

Find an IBCLC

How to spot tongue/lip ties & get free expert advice

Self Help for tongue tie and latch (photos and descriptions which may help you find tongue tie yourself, plus tips on improving latch)

Breastfeeding with an upper labial tie (lip tie)

Trouble Breastfeeding? Look in your baby's mouth. (Overcoming lip and tongue tie with an older baby)

To share with a reluctant provider: The American Academy of Pediatrics' newsletter on tongue tie and breastfeeding

The Myths About Painful Breastfeeding

Tongue Tie Photo Gallery

I hope you don't have to jump through as many hoops as we did, and I hope you have someone closer to you who is an expert in the field. See the list of frenotomy surgeons here to find one near you: http://www.lowmilksupply.org/frenotomy.shtml

Cheers, and happy breastfeeding!

She's about 7.5 months here.


WARNING ON NEXT PIC: Post revision scar of the lip tie - might make some squeamish! Before's on the left, after's on the right. The whole look of her face changed! The before pics were takes two weeks before the after.

Her posterior tongue tie - very hard to diagnose unless you know what to look for.

Here is a video on finding a posterior tongue tie:

This is an excellent video on post-frenectomy exercises: Frenectomy Exercises with Melissa Cole of Luna Lactation

If you need help with breastfeeding, or suspect your baby has a tongue or lip tie, a Breastfeeding Counselor , La Leche League Leader, Nursing Mother’s Counsel or International Board Certified Lactation Consultant may be able to help.

Have you breastfed a baby with tongue and/or lip tie? Did you find the help you needed in your area?

Good for the Whole Family

I’ve often heard moms say that they don’t have time to breastfeed because they have older children to take care of. They don’t have time to “sit around nursing all day”. So what if you do stop breastfeeding so that you can have more time to spend with your older children? What does that teach the older children? That baby’s needs don’t matter? That if something is inconvenient then you just switch to something easier, even if the inconvenient thing was better? The truth is kids are really inconvenient (not to mention loud, messy, and demanding). Why is breastfeeding so often at the top of the list of things to be tossed? I love how this mom points out, “Some portion of ‘The Family Schedule’ belongs to you (the nursing baby).”

I was there once. I was surprised when I heard myself think it. I considered not breastfeeding because it would take too much of my time and energy to do it. How could I, of all people, consider that as an option? My situation was a little different than most because my baby was a bit of a surprise and came to us through adoption, so I had no milk. I was needing to induce lactation.

Baby came home to us in July 2009 at 18 days old. My older kids, two boys, "Scootch", 7, and "Curly", 9, were on summer break from school. However, we had decided that when school began again in August they would not be going back. From now on we would be homeschooling. Several people asked me when we got the baby, “You’re not still going to try to homeschool are you?” The truth is the thought never crossed my mind not to. We had taken a long time to make this decision to homeschool. We had decided that this was what was best for our two boys. Now that we had a new baby girl the needs of my boys did not suddenly change. It was still best for them to stay home. The reverse was true as well. This baby needed to be breastfed, regardless of the schedules and needs of other family members.

Baby sister meets big brother 

When my boys were babies I took all of the time I needed to make breastfeeding work. Why should it be any different for this baby?

I had about 6 weeks of summer left and I started the process of relactating. It was so frustrating to have this baby and no milk! It took a lot of time. A few weeks into the school year and I was beginning to doubt that I could do it all. To make things even harder she was premature weighing 3 lbs 2.8 ounces at birth, and only 4 lbs 0 ounces when she came home. She had a weak suck and she could not draw milk through an at breast supplementer meaning I needed to spend even more time pumping and bottle feeding while practicing at the breast.

I confided in my good friend, “I don’t know if I can do it. I don’t have the time. How can I do a good job homeschooling the boys when I’m spending so much time with her trying to bring in a milk supply? All the time at the breast, pumping, mixing formula and preparing the bags for the Lact-Aid. Maybe I should just give up on the whole breastfeeding thing.”

My friend could see the bigger picture when I could not. “It is important to the boys too. Their sister is important to them. Let some of the school work and other things go.” That was over 3 years ago and I still remember her words. She is important to them.

Scootch and Baby sister

She was right. This tiny baby girl meant everything to the boys. They loved their little sister. This was just as good for them as it was for her. I couldn’t see it then, but three years later I can see it.

Curly and Baby sister

What did they learn by watching me work so hard to breastfeed her? First, they learned an awful lot about inducing lactation! They would watch me pump. When I first started to get drops of milk Scootch (7) walked up and saw the little bit of milk in the bottle. He started jumping up and down and called for his brother to come see, “She’s getting milk, she’s getting milk!” I had no idea they’d be so excited.

They watched me spend countless hours nursing their little sister. They watched as the bottles were replaced by the Lact-Aid, and then the formula supplements gradually went away altogether.

They learned that their little sister was important. That babies are important and that they deserve to have their needs met. They learned that nursing was important, even if you don’t make enough milk. They learned that everyone in the family is important, and that we do what we need to do to take care of each other. They’ve learned that family is more than just DNA.

We did school work while I wore baby sister in the Moby wrap. When she got bigger, they wanted to wear her in the back pack. They were learning how to love and care for a baby.

They wanted her to have the best, just like I did.

The fact that she was important to them was reason enough to spend the time and work hard for breastfeeding to work, even if it meant I had less time to spend doing certain things with them.

Letting her play with their Legos is proof of how much they love her!

One homeschool project was building a sled for little sister.

Now that she is three, she knows how to pester her big brothers, and she does! She can be the annoying little sister, but these boys love this little girl. They would do anything for her. Taking the time to bring in a milk supply and breastfeed her did not take away from them, instead it gave them, and all of us so much!

Then there is always this argument:

Increasing milk production and weaning from supplements

Before working to increase milk supply, make sure there is a true supply issue first! Take a look at these articles to first see if you have low milk production:

• Help, my milk supply is low! Or is it?
• I’m Worried My Milk Supply is Drying Up, What Can I do!?

The golden rule of milk production: The more frequently and completely the breasts are drained, the more milk will be produced: How Mother’s Milk  is Made

Increasing milk production:

• offer both breasts two times at every feeding
• use breast compressions
• nurse frequently (at least 12-14 times in 24 hours)
• increase skin to skin contact
• rest, and stay hydrated

What this process looks like:

Offer baby the first breast and allow him to nurse as long as he likes. When he starts to slow down on his sucking/swallowing start doing some breast compressions. When you squeeze your breast you should see baby respond with an increased sucking/swallowing. Baby has “finished” the first breast when breast compressions no longer get baby nursing more, baby falls asleep or lets go of the breast. When baby has finished the first breast offer the second breast. Repeat the above steps with breast two, (offer breast, use breast compressions and allow baby to finish the breast) then repeat the whole process again with both breasts. If baby is still hungry after taking both breasts two times, then you can continue the process, nursing on one side and then the other, until he is full and/or falls asleep.

Mom resting with baby after nursing with a starter SNS

When working to increase milk production, increase milk intake, or work to eliminate supplements, spending as much time as possible resting with baby skin-to-skin on your bare chest, encouraging frequent nursing, can make a big difference in a short amount of time. This can also be a chance for mom to rest, with baby napping on her bare chest. It can be a great time to have a movie marathon. If you have older children they can be movies to entertain them while you and baby rest and nurse.

Supplement in a way that supports breastfeeding:

Consider using an at breast supplementer instead of bottles for the supplemental milk. This will provide extra stimulation to your breasts and prevent a preference for bottles.

Lact-Aid at breast supplementer

If you are using bottles make sure you are giving them in a way that supports breastfeeding and minimizes flow preference. Bottle feeding in a way that supports breastfeeding includes:

• Using a slow-flow soft bottle nipple that has a wide base and a shorter, round nipple (not the flatter, orthodontic kind).
• Starting by resting the tip of the nipple on the baby's upper lip and allowing him to take it into his mouth himself, as if he were nursing.
• Keeping the bottle only slightly tilted, with the baby in a more upright position, so he has to work to get the milk out. If you hold the bottle straight down, the milk will come out too fast, and he may feel overwhelmed by the flow (Kassing, 2002).

More information on bottle feeding in a way that supports breastfeeding: 

How to Bottle-feed as You'd Breastfeed

Baby-Led Bottle Feeding

If you are currently supplementing with a bottle at every feeding, baby may expect that the time at the breast is always followed by a bottle. If you are using an at breast supplementer at every feeding, baby may expect the constant flow of milk from the tubing whenever he is at the breast. The first step towards eliminating supplements is to get baby comfortable with nursing without supplements at every feeding. Begin by encouraging comfort nursing between feedings, for at least a few days, before you begin to eliminate supplements. If baby is using a pacifier between feedings begin to replace the pacifier with your breast as much as possible.

The Finish at the Breast Method can be a great way to supplement with the bottle and encourage more breastfeeding. You may have heard to breastfeed first, then finish with the bottle if baby didn't get enough. Sometimes it works better to turn things around as described here. The "Finish at the Breast" Method of Bottle Supplementation

Nursing without supplementing

Weaning from supplements:

If baby is gaining weight on target and is showing signs of getting enough milk then you can safely begin to wean off of supplemental milk.

One way to do this is to start by eliminating the first supplemental feeding of the day. First determine what time in the morning you give the first supplement. Try eliminating that first supplement of the day. You may be able to eliminate it completely, or you may need to start by delaying it by about an hour or two.

Follow the steps above to nurse multiple times on each breast and use breast compressions. If baby is still having enough wet diapers (5 per day, plus at least 3 poops if baby is under 4-6 weeks old) then after a few days you can eliminate the next supplement of the day. Eventually you will get to where you are only giving one supplement in the evening and that will be the last one to drop.

Common Questions and Concerns:

I’m afraid to cut back on supplements, I ‘m worried my baby will starve!

Taking away one supplemental feeding will not cause your baby to starve or get dehydrated. You need for baby to be hungry enough to want to nurse more as that will increase your milk production. You can always go back to more supplemental milk if you realize you cut back too much too soon.

I tried eliminating the first time I usually supplement, but baby was screaming and refusing to nurse any more before it was time for the next supplement.

Go ahead and give the next supplement. You can simply delay the time of the first supplement instead of just eliminating it. If you were to delay that first supplement by one hour every day, by 24 days you would no longer be supplementing.

My baby seems hungry 10 minutes after taking both breasts. Does that mean it is time to give a supplement?

No. If baby is hungry again soon after nursing on both sides, offer both sides again. And again. Your breasts are never “empty”. As you continue to nurse, your body continues to produce milk.

How can I nurse so frequently? My breasts don’t have time to “fill up”.

Your breasts are never empty and don’t need time to “ill up”. “The emptier the breast is, the faster it tries to refill - similar to an automatic icemaker. Emptier breasts make milk faster than fuller ones (How Mother’s Milk is Made).”

If I eat better and drink more water, will I make more milk?

“Research shows that the mother's diet, her fluid intake, and other factors have little influence on milk production. If the "milk removal" piece of the puzzle is in place, mothers make plenty of good milk regardless of dietary practices. If the "milk removal" part isn't there, nothing else can make up the difference (Smith, 2001).”

Should I be pumping to increase supply?

The more milk is removed the more milk you will produce. Pumping will remove more milk and help to increase your milk production. However, if you are nursing at least 12-14 times in 24 hours it will be hard to fit in pumping. Some thnigs to ask yourself include: Is it worth the additional stress? Would it be better to spend that time resting with your baby skin-to-skin? If you do pump, you can use it to replace any other milk you have been using to supplement.

If you need help with breastfeeding, a Breastfeeding Counselor , La Leche League Leader, Nursing Mother’s Counsel or International Board Certified Lactation Consultant may be able to help.

Resources

Book: The Breastfeeding Mother's Guide to Making More Milk By West and Marasco

Bottles and At Breast Supplementers

At Breast Supplementers

Bottles

Lact-Aid at breast supplementer

Milk Production

Help, my milk supply is low! Or is it?

How Can I Increase My Milk Supply?

How Mother’s Milk  is Made

I’m Worried My Milk Supply is Drying Up, What Can I do!?

Is Baby Getting Enough Milk? 

Pumping to Increase Milk Production

More

Frequently Asked Questions About Nursing Adopted Babies (scroll down to “Managing Supplemental Feeding”)

Skin-to-Skin Care

What is breast compression and how is it done?

References

Smith, L. (2001). How Mother's Milk is Made. http://www.lalecheleague.org/llleaderweb/lv/lvjunjul01p54.html

Kassing, D. (2002). Bottle-feeding as a tool to reinforce breastfeeding. Journal of Human Lactation, 18(1),56-60

Preparing for Your Return to Work: The Breastfeeding Mother’s Guide

When a family is expecting a baby, it’s a time full of wonder and happy expectation. For months, a mother feels fluttering and quickening, the soft movements of her baby. For many families, it is also a time for making plans to welcome a new family member. Parents may also use the time of pregnancy or the waiting period for adoption to investigate how to support the breastfeeding relationship in the workplace or in school. This article addresses some common questions breastfeeding mothers have about preparing for a return to work and includes the concerns that mothers who do not have a pro-breastfeeding workplace or school may face.

Talk to your employer

This article, Pumping 9 to 5, provides some information on how to talk to your employer about breastfeeding and how to make a plan for expressing your milk at work. Being ready for this conversation, with an idea of what you will need in terms of space and time, will help make your points clear and concise. Take the time you need to make a plan before you speak with anyone at your school or job. Other workplaces, tribes, and many places of higher education have set up lactation rooms; think about bringing them up in your conversation to support your requests. It may also be important to mention the ways your workplace or school will benefit from setting up a lactation room for other families. This booklet explains some of the possible concerns that a business or institution may have about setting up a lactation program for individuals that either work in or attend the facility.

Know your rights

There are State and Federal Laws in place to support breastfeeding mothers. For example California Labor Code 1030-1033 stipulates:

Every employer, including the state and any political subdivision, shall provide a reasonable amount of break time to accommodate an employee desiring to express breast milk for the employee's infant child. The break time shall, if possible, run concurrently with any break time already provided to the employee.

Additionally, the IHS and many Government agencies provide pumping breaks for their employees, and many institutions already have supportive programs in place for breastfeeding mothers. The Affordable Care Act of 2010, states that:

Effective March 23, 2010, the Patient Protection and Affordable Care Act amended the FLSA to require employers to provide a nursing mother reasonable break time to express breast milk after the birth of her child. The amendment also requires that employers provide a place for an employee to express breast milk.

Consider all of your options

Are you able to change your work schedule or delay returning to work or school? Some mothers have worked out job shares or found other ways to minimize separation from their babies. Talk to your employer about what might work for you.

• Some companies offer on-site day-care or allow a mother to bring her baby to work with her so that she may continue to breastfeed. This arrangement eliminates the need to express milk because the mother can breastfeed her baby throughout the work day. Plan ahead: many on-site day-care facilities have long waiting lists.
• Working from home part or full time is an option in some situations.
• If you are not able to bring your baby with you or visit him during the day, consider a day-care situation that would allow a care-provider to bring him to you.
• Split the work week with a co-worker who is looking for extra hours or a partial shift.

When should I start expressing milk? 

Babies grow so fast! They are newborns for only a few weeks, and before you know it, they are smiling, cooing, and reaching for your face while you are nursing. In the first several weeks after birth, take all the time you can to relax, get to know your baby, and just enjoy being his mom. Unless you have to return to work right away, it is recommended that mothers wait until breastfeeding is well-established before they begin expressing milk for returning to work: for most mothers, somewhere between 3-4 weeks. If you have to return to work earlier than 4-6 weeks, you might wish to begin pumping milk two weeks before you plan to return to work.

Learn how to express your milk

Preparing for your return to work or school can begin with learning to express your milk.

• You can express milk by hand, with a breast pump, or by using a combination of the two. 
• Learning how to remove milk without your baby requires both developing your own expression technique and conditioning your milk ejection reflex (MER) or “let down” to respond to it. 
• Most mothers experience MER in response to the sensation of their babies suckling as well as other stimuli like the sound of a baby crying. If you are having trouble eliciting MER during expression, try visualizing your baby at the breast or listening to a recording of your baby's cry. Looking at pictures of your baby or smelling your baby's clothes or a blanket may also be helpful. If you have a video feature on your phone, try recording your baby breastfeeding so you can play it back while expressing. One study indicated that mothers who replicated their babies’ sucking patterns by adjusting the cycle settings on their pumps expressed more milk (Meier, et al, 2012). 
• Warming the breast before expressing and gentle breast massage (working from the armpit towards the nipple with a soft kneading touch or in a circular motion with flat fingers) has been effective at increasing the amounts of milk removed during expression (Jones, Dimmock & Spencer, 2001). 
• Combining hand expression and massage with a pumping routine has been shown to assist with increasing milk production and output (Morton, Hall & Wong, 2009).

How do I hand express?

Hand expression requires no special equipment and can be an effective way for you to remove milk when separated from your baby. Some mothers find that hand expression is more effective for them than pumping because it is more comfortable, and they can feel for areas of fullness and apply pressure with their fingers exactly where it is needed. Once you have success with a method of hand expression, you may feel that you are able to meet your baby’s needs without a pump.

What type of pump should I use?

A high-quality, full-size, double-electric pump is recommended for a mom who plans to pump milk every day. A pump that is made by a manufacturer specializing in breastfeeding equipment will be of higher quality than cheaper pumps made by a company whose primary products are bottle-feeding equipment or baby food. A breast pump is an item for which the old adage, “You get what you pay for,” often rings true. Another option for many mothers is renting a multiple-user pump from a trusted source such as a Hospital, Tribal Health Clinic, or local IBCLC. Most WIC offices provide pumps to moms who are returning to work or school; contact your local WIC office to see if you qualify. Many families have health insurance that is willing to cover the cost of renting a hospital-grade pump. If you are able, call your insurance provider for the details of your own coverage when you are pregnant. Recent 2011 news from the IRS states that electric pumps are now tax deductible, so keep your receipts for your tax records.

In our opinion, the top single user pumps on the market today are:

Pump Brand/Model	Cost range	Warranty	Mechanics	WHO-CODE
Spectra S1 or S2	$115-250	2 year	Closed system	Compliant
Hygeia Enjoye*	$180-300	3 year	Closed system	Compliant
Ameda Purely Yours	$150-180	1 year	Closed system	Compliant
Medela Pump in Style	$250-350	1 year	Open system	Non-compliant

*Sold in the category commonly referred to as single-user pumps; Hygeia is the only pump company that has sought and received FDA approval for their pump to be used by more than one person.

What is the difference between an open and closed system pump? 

With an open system, if milk or condensation makes its way into the tubing, it is possible for mold to begin to grow in the motor. There is no way to clean the pump motor, and any mold spores present could come through the tubing and possibly into contact with the expressed milk. Furthermore, if the pump is second-hand or was used by another mother, germs from one mother or her milk could contaminate the milk in the same way. An open system is built to be a single-user system only.

Closed system pumps are just what they seem: there is no way for the milk to come into contact with the motor. Theoretically, any closed system pump could be safely used by more than one person (each with her own tubing and other external pump parts). 

What is the WHO CODE, and why is it important to consider when buying a breast pump?

The “WHO CODE” is short for the World Health Organization’s International Code of the Marketing of Breastmilk Substitutes. Part of the purpose of the WHO CODE is to protect breastfeeding by preventing aggressive marketing of breastmilk substitutes and artificial nipples. Many people prefer to purchase a breast pump from a company that is supportive of and compliant with the WHO CODE.

More information on both the breast pumps, the WHO CODE, and open and closed systems can be found at: The Problems with Medela

How often should I express milk?

Once a day is usually plenty at the beginning. Most moms find that they are able to express the most milk in the morning hours. You can nurse your baby on one side while expressing milk on the other side. Or you could pump both sides about one hour after your baby’s first morning feeding. Don’t worry if you don’t get very much milk at first. It takes practice, and your body needs to “learn” to make milk for that extra “feeding.” When milk is removed, your body responds by making more milk at a faster rate. It can take a few days for your body to increase production (Daly, Kent, Owens et al.,1996). Any milk collected during these practice sessions can be stored in the freezer.

How much milk should I have stored in my freezer?

Many mothers find that they feel less stress if they to know that they don't need to create a large freezer stash of milk before they return to work. Instead, they can use their maternity leave to focus on being with their babies and getting breastfeeding well-established. If you have enough milk to send with your baby on your first day, then you have enough in the freezer.

It is important to express as much milk while you are at work as your baby needs during that time. If your baby needs 10 ounces while you are away at work, then you need to pump at least 10 ounces each day.
For example:
If you were to only pump 8 ounces and send 2 ounces from the freezer each day, you would not be expressing the amount of milk your baby requires. Your body will “think” that your baby needs 2 fewer ounces each day than he really does, and your production will not match his demand. If you start to run out of milk in your freezer, you may face the difficult decision of how to meet your baby’s needs. Many mothers learn too late that increasing their milk supply to meet their baby’s demands is more complex than it seems. Meeting your child’s daily needs for expressed milk during separation is the best way to avoid difficulties later.

Using the simple system described, you pump each day what your baby would need the next day. This way you only use the small freezer stash for emergencies, such as dropping and spilling a day’s worth of milk, or other milk-related calamities.

If you need information about returning to work or expressing your milk, a Breastfeeding Counselor , La Leche League Leader, Nursing Mother’s Counsel or International Board Certified Lactation Consultant may be able to help. Accessing a community support system can help you reach your breastfeeding goals.

You may also be interested in these articles:
Returning to Work: The Breastfeeding Mother’s Guide
Are There Differences Between Breastfeeding Directly and Bottle-Feeding Expressed Milk?
Breast versus Bottle: How Much Should Baby Take?
Facts Every Employed Breastfeeding Mother Needs to Know
I’m Worried My Milk supply is Drying Up, What Can I Do?

References
Black Bear, J. (2011). Breastmilk Storage and Handling Guidelines. http://nativemothering.com/2011/04/breastmilk-storage-guidelines/

Daly, S., Kent, J., Owens, R. & Hartmann, P. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiol, 81(5), 861-75.

Easy Steps to Supporting Breastfeeding Employees. (2008). U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau. Produced in contract with Every Mother, Inc. and Rich Winter Design and Multimedia. http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/easysteps.pdf

Forbes, B. (2011). What is the WHO-CODE? Website: http://www.bestforbabes.org/what-is-the-who-code

Internal Revenue Bulletin. Lactation Expenses as Medical Expenses. (2011). Website: http://www.irs.gov/irb/2011-09_IRB/ar11.html

Jones E., Dimmock, P. W. & Spencer, S. A. ( 2001). A Randomised Controlled Trial to Compare Methods of Milk Expression After Preterm Delivery. Arch Dis Child Fetal Neonatal Ed, 85, F91–F95

Meier, P. Engstrom, J. Janes, J. Jegier, B. & Loera, F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32, 103-110

Morton J., Hall, J., Wong, R., Thairu, L., Benitz, W. & Rhine, W. (2009) Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology, advance online publication,29, 757-764

Shebala, M. (2012, January 26). Benefits of breastfeeding in workplaces touted. Navajo Times, http://www.navajotimes.com/opinions/2012/0112/012612notebook.php

Silver, B. (2010). College and University Lactation Programs, some Additional Considerations. The Elsevier Foundation, University of Rhode Island Schmidt Labor Research Center.http://www.uri.edu/worklife/family/family%20pics-docs/LactationPrograms%20FINAL.pdf

Simmance, A. (2011). Why You Shouldn't Buy, Sell, or Borrow a Second Hand Medela Swing Pump. Website: http://mythnomore.blogspot.com/2011/08/why-you-shouldnt-buy-sell-or-borrow.html

State of California, California Labor Code § 1030.
2002: Chapter 3.8, Section 1030, Part 3 of Division 2 of the Labor Code http://www.google.com/url?q=http%3A%2F%2Fwww.cdph.ca.gov%2FHealthInfo%2Fhealthyliving%2Fchildfamily%2FPages%2FCaliforniaLawsRelatedtoBreastfeeding.aspx%23workingandbreastfeeding&sa=D&sntz=1&usg=AFQjCNHUWIwkLISI2im9IiolxL9ZB-IVhA

West, A. (2011). The Problems with Medela. Website: http://www.justwestofcrunchy.com/2011/01/19/the-problems-with-medela/

© 2012 Serena Meyer, IBCLC and Teglene Ryan

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Returning to Work: The Breastfeeding Mother’s Guide

Returning to work after giving birth can be stressful for many mothers and their families. It is often hard to adjust to being both a mother and an employee, and you may have mixed feelings about leaving your baby. Mothers often report that they are sad to leave their children, and it is normal to feel hesitant or reluctant to part with the small person who holds a lion’s share of your heart. Both new and veteran parents worry about childcare for their new infants. You may be wondering how your baby should be fed when you are away and how milk you should leave at daycare. This article will address some common questions breastfeeding mothers have about continuing to breastfeed and providing breastmilk for their babies after returning to work or school.

How much milk will my baby need while I’m away?

Breastfed babies need, on average, 24 to 32 ounces of milk per day (Kent et al., 2006). If you spread that amount over a full day it equals 1-1.25 ounces per hour. With that information in mind, plan on leaving about 1-1.25 ounces of milk for each hour of separation. Most breastfed babies need no more than 2-4 ounces at each feeding (Kent et al., 2006). Breastfed babies need less milk than formula-fed babies do, and unlike with formula, the amount of breastmilk your baby needs does not increase as he grows bigger. When you return to work, your baby will need only a portion of this daily amount of milk from the care provider, because he will still be getting much of it by breastfeeding during the hours of the day and night when you are together.

Offering smaller bottles, of no more than 2-4 ounces, means there is a smaller chance that your baby will not finish his bottle and leave milk that must be thrown away by licensed daycares.

How many times do I need to express milk at work?

How many times you pump at work will depend on a few factors: how long you are away from baby, how well you respond to milk-expression, and your work situation. Many working moms plan to pump milk at least as often as every 3 hours. If you are becoming engorged between pumping times, you may need to remove milk more frequently. Every mother has her own “magic number” and will differ in how frequently she needs to express her milk to both maintain milk production and provide enough expressed milk for her baby. Try to remove milk as often as it takes to collect enough for your next work day.

What if I can’t stop to pump as frequently as I would like?

When it is challenging to find enough time to pump your milk, here are some time-saving options:

• Breastmilk can be kept at room temperature for 6-8 hours (ABM, 2004). With this guideline in mind, you do not need to take time to wash out your pump parts after every use. Keep your pump parts and bottles of milk in a cool place, and cover them with a cool towel; a small cooler or insulated lunch pack is another option.
• Some mothers place all of their pump parts in the refrigerator along with their bottles of expressed milk each time they pump. At the end of the day, they take all of the parts home to wash.
• Consider arranging your schedule so that you can arrive at work 15 minutes before you need to “clock in” and pump before you start work. 
• If you don’t have enough time to completely drain your breasts, it is still valuable to stop and express some milk, even if it you only have 5 minutes.
• If expressing in your car could help you save some time, consider purchasing a car adapter for your pump and a hands-free pumping bra (or you can make your own) so that you can pump with your hands free. For your safety, we recommend that you do not express milk while driving.
• If you are mobile during your work hours, a cooler for your milk will help preserve your milk at a lower temperature, and you can save time by expressing milk whenever you have an opportunity.

How should I store the milk I pump at work? Do I put it all in the freezer?

In order for your baby to get the most anti-infective properties from your milk, it is best to offer it fresh whenever possible. Freezing has been found to denature some of the antibodies and kill some of the living cells in milk (Orlando, 2006; Buckley & Charles, 2006). Whether fresh or frozen, your milk provides all the nutrition your baby needs, and you can count on your milk to support your baby in all areas of growth and development.

Here is a schedule many working mothers recommend for using frozen milk. With this system, your baby gets more fresh milk and therefore the best possible nutrition and immune factors to protect him from illness:

• Pump on Monday; give this milk to your babysitter to use on Tuesday.
• Pump on Tuesday; use this milk on Wednesday and so on until Friday.
• Pump on Friday, label with the date, and freeze this milk; put it in the back of the freezer.
• Use the oldest milk in the freezer for Monday.
• Use your freezer stash only when you have an unusual need for extra milk, for example, when your baby is going through a growth spurt or you accidentally spill all of your freshly-pumped milk.

This system prevents the frozen milk from getting too old and needing to be thrown out. Another option would be to refrigerate Friday’s milk over the weekend and let your babysitter use it on Monday. This practice would preserve more of the antibodies in Friday’s milk but would not use up your frozen milk before it goes out of date.


What if my baby’s caregiver says my baby needs more milk?

With bottle-feeding, there can be a tendency for the person feeding to encourage the baby to finish the bottle. Milk flows easily from a bottle nipple, even when the baby is not actively sucking, and the faster flow can cause a baby to continue feeding after he is full. Caregivers may believe that a baby needs more milk than he actually does, and many childcare workers are accustomed to the larger amounts of formula they feed many babies. Make sure that your caregiver has the correct information about how much breastmilk a baby needs and understands the difference between bottle-feeding breastmilk and formula.

You can offer some tips to your baby’s caregiver on how to bottle feed in a way that supports breastfeeding:

• Use a slow-flow soft bottle nipple that has a wide base and a shorter, round nipple (not the flatter, orthodontic kind).
• Start by resting the tip of the nipple on the baby's upper lip and allow him to take it into his mouth himself, as if he were nursing.
• Keep the bottle only slightly tilted, with the baby in a more upright position, so he has to work to get the milk out. If you hold the bottle straight down, the milk will come out too fast, and he may feel overwhelmed by the flow (Kassing, 2002).

What if my baby is refusing bottles?

If your baby is refusing bottles, or you prefer not to use one, there are other options available:

• You can try cup or spoon feeding. If you use either a cup or spoon, make sure your baby is fed while sitting in an upright position and that the feeding is “paced” (slow).
• If your baby continues to avoid any type of feeding while you are away, despite offering your milk from a spoon or cup, you may want to investigate slow-flow sippy cups (avoid ones that encourage babies to bite the tip to get milk).
• Some mothers have said that offering frozen milk in a mesh feeder worked for them; babies may respond favorably to the new texture and temperature of the milk.
• Investigate whether you can have your baby brought to you by your care-provider during a break so that you can nurse.
• Another option, when your baby is refusing expressed milk, is offering to make up missed feedings when you are together. This is often called reverse cycling.
• If your baby is over 6 months, and ready for solids, you can send foods for him that have a higher content of water such as melon. Your baby will ideally be able to get an amount of your milk in some way, but there are other ways to cope with hydration issues if your baby is unwilling to take your milk in a liquid form.

What if I’m not expressing enough milk?

Here are some tips to increase the amount of milk you are expressing:

• Go back to the basics of learning how to express your milk.
• Relax. Take a few deep breaths and get comfortable before you begin expressing your milk.
• Avoid watching the bottles to see how much milk is coming out. Instead, focus on your baby, listen to music, or try some relaxation methods. Many mothers find that watching how much milk is coming out reduces the amount they are able to express. Try covering the bottles with a cloth or towel, so they are not visible. There is evidence that music can be soothing to mothers while they are pumping and improve milk-removal. Music-based practices have been shown to encourage better milk production in mothers who have babies in the nicu (Keith, D.R. et al., 2012).
• Add another breastfeeding session, especially if your baby is sleeping 5 or more hours in a row at night. 
• If you are unable to express more frequently at work, another option is to express milk at home first thing in the morning.
• Try more frequent, shorter sessions of expressing milk. Many mothers have said that several 20-minute sessions will yield more total milk than a couple of 30 minute sessions.
• Send what you are able to express. Nurse at drop-off and pick-up to decrease the total amount of milk needed while you are separated. Remember that your baby has 24 hours in the day to get all of the milk he needs. If he does not get enough in the time you are apart, he can nurse more when you are together in order to get the total amount he needs.
• If you are using a pump, check its condition. Some pumps need parts replaced frequently to maintain full suction.
• Rule out any health-related complications to milk production with your health-care team; there are many reasons that mothers experience a dip in supply.
• Try “hands on pumping” when you are expressing milk to empty the breast.
• Use some gentle massage before you express: starting in the armpit and work toward the nipple in gentle, circular motions. 
• Update the pictures of your baby that you are using when you are expressing. Bring some worn baby pajamas and try smelling them to help you mentally bring your baby into the room with you. Some mothers have said that recordings of their babies are also helpful. One mother reports that creating a sound file of her baby’s sounds and favorite lullabies together was most effective for her.

If you need more information about returning to work or expressing your milk, a Breastfeeding Counselor , La Leche League Leader, or International Board Certified Lactation Consultant may be able to help. Accessing a community support system can help you reach your breastfeeding goals.



You may also be interested in these articles:

Preparing for Your Return to Work: The Breastfeeding Mother’s Guide
Baby-Led Bottle Feeding
Breast versus Bottle: How Much Should Baby Take?
Facts Every Employed Breastfeeding Mother Needs to Know



References

Academy of Breastfeeding Medicine. (2004). Clinical Protocol Number #8: Human Milk Storage Information for Home Use for Healthy Full Term Infants [PDF-125k]. Princeton Junction, New Jersey: Academy of Breastfeeding Medicine.

Buckley, K. Charles, G. (2006). Benefits and challenges of transitioning preterm infants to at-breast feedings. International Breastfeeding Journal, 1,13

Callahan, A. (2012). Pump Up the Music: Improving Breast Milk Production in the NICU. Website: http://scienceofmom.com/2012/04/12/pump-up-the-music-improving-breast-milk-production-in-the-nicu/

Kassing, D. (2002). Bottle-feeding as a tool to reinforce breastfeeding. Journal of Human Lactation, 18(1),56-60

Keith, D.R., Weaver, B. & Vogel, R. (2012). The effect of music-based listening interventions on the volume, fat content, and caloric content of breast milk-produced by mothers of premature and critically ill infants. Advances in Neonatal Care, 12(2):112-9.

Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.

Mellentine, K. (2003). Converting a Regular Bra into a Pumping Bra. Jan Andrea, at home on the web. Website: http://www.sleepingbaby.net/jan/Baby/pumping_braconvert.html

Orlando, S. (2006). The immunologic significance of breast milk. J Obstet Gynecol Neonatal Nurs, 24(7), 678-83

Stuebe, A. (2011). Podcasts for Breastfeeding. itunes. Apple, Inc. Website:
http://itunes.apple.com/us/podcast/podcasts-for-breastfeeding/id432087823#



© 2012 Serena Meyer, IBCLC and Teglene Ryan, IBCLC