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Archive for September, 2010

Barbara Wilson Clay, BSEd, IBCLC kindly offered to explain this widely used term “nipple confusion”…..

Occasionally a baby will have difficulty breastfeeding normally. The reasons for this may include:

• The infant is small, or born before the due date
• A difficult or complicated birth
• The infant or mother is ill, or recovering from illness
• Structural abnormality of the baby’s face or mouth
• Structural abnormality of the breast or nipple

When poorly feeding infants are offered a bottle, they then may appear to reject the breast. This is not nipple confusion, but an indication that the infant needs help to breastfeed successfully. In these cases, the baby’s refusal to breastfeed stems from inability rather than preference.

The term nipple confusion most appropriately refers to an otherwise normal infant who has had too many bottles before breastfeeding has been well established.

Sometimes nipple confusion occurs in an older baby, previously nursing well, whose mother has returned to work or school. If the mother’s milk supply is low due to lack of stimulation during separations, the baby may begin to prefer the quick, easy flow of the bottle. The key to reversing this situation is to re-stimulate the mother’s milk supply. Mothers also can gently re-focus on the breastfeeding relationship by nursing more often when at home with the baby and cutting back on the number of optional bottles.

Another type of nipple confusion refers to a baby who refuses to accept a bottle! Breastfed babies love to breastfeed. In such situations, offer the bottle in a low-key manner. Keep practice sessions playful. Reassure the baby often, and stop whenever baby seems stressed. By continuing to offer tastes from the bottle, baby will soon get the idea. Some babies will not accept a bottle from the mother, but will accept a bottle from a father or a babysitter.

Some older babies prefer to drink pumped milk from a cup, or mixed with solids from a spoon. They may never need to use a bottle.

Pointers: If Your Baby Seems Nipple Confused:

• Increase skin-to-skin contact to calm baby
• Use of a nipple shield can help coax these infants back to the breast.
• Use of a feeding tube device such as the SNS can provide an increased milk flow allowing supplementation at breast
• Protect breastmilk supply by increased breastfeeding/pumping

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Many women are concerned about whether they are producing enough breastmilk.  Dr Jack Newman MD, FRCPC has compiled a list of 7 points that highlight what are NOT good ways of judging.

1. Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby’s requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.
2. The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is “too good” may not be getting enough milk. There are many exceptions, but get help quickly.
3. The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. Do not limit feeding times.  “Finish” the first side before offering the other.
4. The baby feeds often and/or for a long time. For one mother every 3 hours or so feedings may be often; for another, 3 hours or so may be a long period between feeds. For one, a feeding that lasts for 30 minutes is a long feeding; for another, it is a short one. There are no rules how often or for how long a baby should nurse. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least 2-3 substantial yellow bowel movements each day. Remember, a baby may be on the breast for 2 hours, but if he is actually feeding or drinking (open wide—pause—close mouth type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk. Contact your breastfeeding adviser with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple, like the Supplemental Nursing System.

5. “I can express only half an ounce of milk”. This means nothing and should not influence you. Therefore, you should not pump your breasts “just to know”. Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is available, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily.
6. The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding.
7. The 5 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has “dried up” or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast (handout #15 Breast Compression) to increase flow.

Notes on scales and weights
1. Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh 250 grams (half a pound) or more, so babies should be weighed naked or with a brand new dry diaper.
2. Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later, by fixing the breastfeeding. Growth charts are guidelines only

If you are breatfeeding your baby on demand, you are most likely producing enough milk.

However, should you have any concerns that you do not have enough milk look for the signs that indicate that your baby is getting enough  – such as weight gain, alertness, sleep and general mood. (as well as urination and bowl movements in the early days)

These 6 tips might help you can increase your breastmilk supply :

1.  Avoid all kinds of artifical nipples (bottles or soothers).  All sucking should be at the breast.

2. Additional use of a breastpump may help to stimulate supply.

3. Herbs, such as Fenugreek, Goats Rue, Blessed Thistle and Fennel Seed have been known for centuries to help increase breastmilk supply.

4. Skin to skin contact with your baby will help stimulate your prolactin; invest in a soft sling which will allow skin contact between you both.

5. Co-rooming (and night time feeding) has also been shown to help with supply.

6. Diet – make sure you are getting enough rest, drinking enough and following a lactogenic diet.

If  you are concerned for you baby consult your healthcare professional.

3. Urination.

With six soaking wet (not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be reasonably sure that the baby is getting a lot of milk (if he is breastfeeding only). Unfortunately, the new super dry “disposable” diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby’s urine should be almost colourless after the first few days, though occasional darker urine is not of concern.
During the first 2-3 days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the standard on which to judge breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother’s milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine that is not red. Fixing the latch, using compression will usually fix the problem (See Protocol to Increase Breastmilk Intake by the Baby). If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 Using a Lactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.

2. Baby’s bowel movements.

For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby’s gut during pregnancy. Meconium is passed during the first few days, and by the 3rd day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving cream in consistency (from air bubbles). The variations in colour do not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements that are becoming lighter by day 3 of life, is doing well.
Without your becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways, next to observing the babies drinking, (see above, and videos at of knowing if the baby is getting enough milk. After the first 3-4 days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least 2-3 substantial yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fourth or fifth day of life, should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not very reliable.

Some breastfed babies, after the first 3-4 weeks of life, may suddenly change their stool pattern from many each day, to one every 3 days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal.
Any baby between 5 and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small, infrequent bowel movements during this time period mean insufficient intake. There are definitely some exceptions and everything may be fine, but it is better to check.

1. Baby’s nursing is characteristic

A baby who is obtaining good amounts of milk at the breast sucks in a very characteristic way. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide–>pause–>close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This same pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told—like feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pauses) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry.

Using a breastpump can seem like a bit of a minefield, especially when you are considering going back to work and have several other things on your mind as well. Expressing breastmilk for your baby during the day is a sizeable commitment and will require lots of forward planning and a fair bit of kit. Once organized however, expressing can easily slot into your day and need not be too much of a mission. The tips below are the 6 most important issues to consider:

1. Invest in as good a breastpump as you can afford.
The best and quickest pumps are double pumps with variations of speed and suction (sometimes called 2-phase expression). Also make sure that the pump is fairly quiet if you will be using it in the workplace.

2. Make sure that you have a suitable place to store your milk at work.
Often there will be a fridge at work (make sure that the milk is stored at the back and not in the door), but if not, invest in an ice pack which will keep your milk cool for up to 8 hours.

3. Invest in a hands-free expressing bra.
This will free you up for tasks such as talking on the phone, writing emails, eating your lunch, etc. They also seem to have a positive effect on your milk yield.

4. You will need a suitable carry-bag with a mini-ice pack inside for transporting your milk safely and hygienically.
Make sure you are very organized and chill the ice packs overnight before work so they are ready to go in the morning.

5. Remember that breast pumps are different to your baby and your breasts may take a while to get used to them.
It is better to begin expressing one or two weeks before you go back to work so that you are already familiar with the drill by the time you get to the office.

6. Take regular breaks to express at set times
Remember to eat a healthy and balanced diet and drink plenty of water.

Breastfeeding mothers frequently ask how to know their babies are getting enough breastmilk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.

Ways of Knowing  my baby is getting enough breastmilk?

1. Baby’s nursing is characteristic – See blog post “Is my baby getting enough milk  – Part One”

2. Baby’s bowel movements – See blog post “Is my baby getting enough milk  – Part Two”

3. Urination – See blog post  “Is my baby getting enough milk –  Part Three”

Express As Much Milk As Possible

If you are using a breastpump to remove (express) milk for your baby, it is very important that you have correctly-fitted breastshields. The breastshield is the part of the pump collection kit that fits directly over your nipple and forms a seal around the areola (the darkened part of your breast).  The breastpump works by creating a vacuum, which gently draws your nipple into the tunnel of the breastshield–just like your baby would draw it into the mouth with sucking.  A correctly-fitted breastshield will help make your pumping comfortable, and allow the pump to remove as much of your milk as possible with each milk expression.

Medela Breastshields – 5 Different Sizes

Medela PersonalFit™ breastshields are available in four sizes:  Medium (24 mm), which is the size in Medela’s breastpump kits; Small (21 mm), Large (27 mm), Extra Large (30 mm), and XX Large (36mm).  Medela’s breastpump kits make it easy to use a larger or smaller breastshield, because all sizes are designed to fit into the same connector on the collection kit.  Many women appear to benefit from a size other than the standard 24 mm breastshield.  In one study, many mums were fitted with either a Large or Extra Large breastshield within the first days after birth, and even more mums eventually used these larger sizes in order to pump comfortably and effectively. It is almost impossible to tell which size breastshield is the best fit without watching the nipple movement during pumping.  The following tips will help you determine whether a different size breastshield would be right for you.  Then, you can discuss your observations with your nurse or lactation specialist.

Choosing the Correct Size Breastshield – Signs to Look For

To determine whether you think you might need a Large or Extra Large breastshield, look at your nipple as it is drawn into the tunnel of the shield during pumping.  It should move freely and easily, and should not rub against the sides of the tunnel.  If the breastshield fits tightly, your nipple will rub against the sides of the tunnel with each vacuum movement of the pump.  After several pumpings, you may notice that the outside of the nipple (rather than the nipple tip) is tender or sore.  You may also see a little ring of skin flecks in the tunnel of the breastshield after you pump.  While a little circle of milk in the tunnel is normal, a ring of skin flecks probably indicates that the tunnel is too small, and that you would be more comfortable with a larger breastshield.  When your nipple moves freely in the tunnel of the breastshield, you will also note a gentle pulling movement in the areola each time the pump cycles.  If you do not see any movement in the areola with the pump vacuum, the breastshield is probably too small.

What Happens When You Use the Wrong Size Breastshield?

A tight breastshield can affect breast emptying and lead to problems with milk supply.  During pumping, your milk flows out of the breast due to a combination of the pump’s vacuum and your milk ejection (or let-down) reflex. However, a tightly-fitting breastshield does not allow good breast emptying–even with the best breast pump and a strong milk ejection reflex–because it squeezes the small ducts inside the nipple that carry your milk out of the breast.  Ordinarily, these ducts increase in size when you feel milk ejection so that the milk can flow out of the breasts quickly and easily.  However, if the ducts are squeezed by a tightly-fitting breastshield, some milk stays behind in the breast.  Eventually, this incomplete milk removal can lead to plugged ducts, mastitis, and problems with low milk volume.  You may note breast engorgement that seems to last a long time–or little “knots” or hardened areas in the breast that do not seem to empty with milk expression.

Choose A Medela Personalfit Breastshield

If you have either or both of these symptoms–nipple tenderness around the outside surface of the nipple or problems with breast emptying– your pumping will probably be improved with a larger size breastshield.  You will want to correct this problem as soon as possible after your baby’s birth before the nipple tenderness and back up of milk in the breasts affect your milk supply.  For more information or to purchase Medela’s PersonalFit breastshields, contact your lactation specialist.

By Paula P. Meier, RN, DNSc, FAAN

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