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Written by Paula P. Meier, R.N., DNSc, FAAN, Rush-Presbyterian St. Luke’s Medical Center.
With thanks to Medela for allowing us to re-produce this article.

Babies classed as premature are unable to suck, and therefore the mothers do need to use a breastpump to exctract breastmilk. Many people think that giving birth prematurely limits a mother’s ability to make enough milk, but this is not true. The extra stress, discomfort, and fatigue that go along with the birth of a premature baby can cause a slow start with milk production. In the first few days after giving birth, mothers may make just drops of milk each time they use the breast pump, so it is easy to get discouraged. Remember, these drops are like a medicine for your baby, because they provide protection from infection. And– this slow start usually gives way to an adequate milk supply by the fifth or sixth day after birth.

Which Breast pump should I use?

Using a hospital grade breastpump to express breastmilk for your premature baby.Studies have evaluated the different kinds of breast pumps available to new mothers. The findings show that mothers who are expressing milk for premature babies should use a hospital-grade electric breast pump-ideally with a double collection kit, so that both breasts can be emptied at the same time. This type of pump is the most effective in stimulating release of the milk-making hormone, prolactin, which results in the greatest amount of milk. Mothers sometimes report that they have received a battery-operated or a less-powerful electric pump as a “baby shower” gift, and want to use it to express milk for their premature baby. While this type of pump is suitable for a mother who uses it only once or twice a day and breastfeeds a full-term baby the rest of the time, it does not provide enough stimulation to establish and maintain a good milk supply for a mother who is pumping for a premature baby. If you have received one of these pumps as a gift, you will be able to use it later-after your baby comes home and is feeding.well from the breast. But, in the first few weeks after premature delivery, you should plan to rent a hospital-grade electric pump.

Premature Baby

How often should I use the breastpump?

During your first few weeks of expressing breastmilk, your should use the pump as frequently as 8-10 times per 24 hour period -about as often as a healthy, full-term baby would feed at the breast in the early days after birth. The purpose of this frequent pumping is to stimulate prolactin during the time that your body is beginning to make milk in plentiful amounts. While you may get only drops of milk at first, frequent pumping is important in building an abundant, long-lasting milk supply. You may not see the results of your pumping immediately, but your efforts should pay off toward the end of the first week of milk expression. Night time pumping helps boost your supply, so speak with the health care professionals about whether you sould be setting your alarm to wake up to pump.

How long should each pumping session last?

In the first few days after birth, most mothers express very small amounts of milk-from a few drops to a few teaspoons-at each pumping. During this time, a pumping session should last from 10-15 minutes, which is enough time to stimulate the release of prolactin. However, after the milk has “come in” several days later, and you produce more than half an ounce at each expression, you should use the pump until your milk has stopped flowing for at least 1-2 minutes. The last droplets of milk released during pumping contain very high levels of fat, which provides most of the calories in your milk. If you stop pumping after 10 or 15 minutes while your milk is still flowing, your baby may not receive these valuable fat calories. Also, your breasts need to be emptied as much as possible–meaning that milk flow has stopped-otherwise your body thinks that the milk left in the breasts isn’t needed, and less will be produced. A few mothers say that the milk never “stops” flowing while they pump. As a general rule, you should not pump for more than 30 minutes, even if milk continues to flow. Also, if you pump for this long at each milk expression, you do not need to pump as frequently as a mother who can express her breasts in less time.

What is a “normal” amount of milk?

Nearly all mothers of premature babies worry about whether they are producing a “normal” amount of milk. Many things affect the amount of milk a mother produces-especially in the first few days after giving birth. A mother of a full-term breastfeeding baby produces only about an ounce of milk during the first 24 hours after birth, but by the 3rd or 4th day is making several times that amount. Mothers of prematures frequently take a longer time to go from a few drops to an ounce or more at a pumping. This condition is referred to as a delayed onset of lactation, and is related more to pregnancy complications-such as bedrest, medications for high blood pressure and premature labor, and Cesarean deliveries-rather than to premature birth itself. No one knows exactly why this is the case, but researchers think that the milk-making hormones or tissues in the breast may be affected temporarily by these complications and medications. A slower onset of milk production does not necessarily mean that a mother will not make enough milk for her baby-only that it may take her a few extra days in the beginning to catch up with mothers who have had uncomplicated deliveries. Ideally, by the end of the second week of pumping, you’ll be producing at least 500 ml (about two cups) of milk each day. This is the amount of milk that your baby will need at the time of hospital discharge. Thereafter, you will want to maintain or even increase this amount so that you have enough milk to feed your baby after discharge hospital discharge.

What is a tongue-tie?
In some babies, the tongue is restricted by a thin membrane underneath it. This can make the tongue look forked, shortened, or heart-shaped when the tip is lifted.

Recent studies have shown that some tongue-tied babies don’t feed well, and will benefit from having the tie snipped by someone suitably trained. The Department of Health has recently issued guidelines on treating tongue-tie in breastfed babies

How can it affect feeding?
Babies need free tongue movement to feed and swallow comfortably. When breastfeeding, they need to press the tongue-tip into the breast, with the nipple far back in the mouth, against the soft palate. If the tongue movement is restricted, they may not attach to the breast fully, or at all. Incomplete attachment to the breast results in lower fat content of the milk, as some parts of the breast are not fully drained.

When bottle feeding, babies need to keep the teat in the mouth and push easily against it.

Possible problems in baby:
• difficulty attaching to the breast and/or staying attached
• very frequent and/or long feeds
• difficulty in swallowing and greater intake of air
• colicky symptoms from increased intake of milk sugar (because fat content is lower, more volume of milk is needed to give the same calories, and this means more lactose in the gut, causing indigestion)
• dribbling at the bottle
• poor weight gain even with copious intake
Later on:
• difficulty in chewing and swallowing lumpy food

Possible problems in mother:
• sore, damaged nipples
• over-supply to compensate for reduction in milk fat (see above)
• reduction in supply over time from the difficulties encountered
• mastitis from poor drainage and nipple trauma
• exhaustion from frequent, long feeds

Other factors which may aggravate the condition or give similar symptoms:
• long labour, and/or difficult birth (eg ventouse, forceps, breech presentation, caesarean birth) causing tension or compression in the head, which may affect tongue movement and make it harder for baby to open the mouth
• swollen breasts from fluid in tissue behind nipple (eg from high blood pressure) or from milk engorgement around 3-4 days
• very large, long or inverted nipples

How can tongue-tie be treated?
We recommend that you do all you can to improve feeding while feeding is under review, or while awaiting referral for treatment. Skilled support in getting your baby into a closer position to attach to the breast more easily will improve symptoms, and may mean that no treatment is needed. An experienced midwife or health visitor, or a breastfeeding counsellor, lactation consultant or other breastfeeding specialist can help with this. Trying different teats for a bottle-fed baby may help. Cranial osteopathy may relieve compression of the head or discomfort from a difficult birth. As time goes on, it may become easier for the baby to compensate for a shortened tongue, and the tie may break later.

Getting good help before treatment also means that any snipping of the tongue-tie will show whether it was actually a factor in the feeding problem.

If there is little improvement from the above measures, the tie can be snipped. This does not damage the tongue at all, takes only a few seconds, and causes little if any pain or bleeding. No anaesthetic is needed, and the baby can feed immediately afterwards. Often the feeding problems improve or resolve. If not, your baby will need to be reviewed for other possible causes of feeding problems.

Where can I get the tongue-tie snipped?
In some areas, treatment is easily available. Ask your maternity unit if there is an Infant Feeding Adviser to arrange treatment. You could ask your GP to refer you to the paediatricians or oral surgeons, but if there are feeding problems, you will need to ask for an urgent referral. You may need to work hard to get support.What can happen if the tie is not treated?
Some mothers are unable to continue direct breastfeeding if there are severe difficulties, but expressed milk could be given if baby can manage the bottle well. In some babies, the tie loosens or breaks on its own, so there is no way of predicting whether a tongue-tie will affect chewing or speech later.

What happens after treatment?
Most babies show improvement in feeding, but this may take some time, particularly if other factors are involved in the problems (see above). It is good to give feedback to all the health professionals involved in monitoring the baby’s progress, so we learn how tongue-tie can affect feeding, and how simple and effective treatment can be.

Dr. Jack Newman is a Toronto pediatrician who has practiced medicine since 1970. In 1984 he established the first hospital-based breastfeeding clinic in Canada, at Toronto’s Hospital for Sick Children. He now holds breastfeeding clinics in several hospitals in the Toronto area.

Here he shares some practical tips on how to get the baby on the breast:

Getting the baby to take the breast
Although many people do not believe that the early introduction of bottles may interfere with breastfeeding, the early introduction of artificial nipples can indeed interfere. The sooner you can get the baby to the breast after he is born, the better. However, babies need flow from the breast in order to stay latched on and continue sucking, especially if they have gotten used to getting flow from a bottle or another method of feeding (cup, finger feeding). So, what can you do?

1. Speak with the staff at the hospital where the baby will be born and let the head nurse and lactation consultant know your plan to breastfeed the baby. They should be willing to accommodate your desire to have the baby fed by cup or finger feeding, if you cannot have the baby to feed immediately after his birth. In fact, more and more frequently, arrangements have been made where the adopting mother is present at the birth of the baby and takes the baby immediately to nurse. The earlier you start, the better.

2. Some biological mothers are willing to nurse the baby for the first few days. There is some concern expressed amongst social workers and others that this will result in the biological mothers’ changing her mind. This is possible, and you may not wish to take that risk. However, this has been done, and it allows the baby to breastfeed, get colostrum, and not receive artificial feedings at first.

3. Latching on well is even more important when the mother does not have a full milk supply as when she does. A good latch means painless feedings. A good latch means the baby will get more of your milk, whether your milk supply is abundant or minimal.

4. If the baby does need to be supplemented, this should be done with a lactation aid with the supplement being given while the baby is breastfeeding . Take a look at the Medela Supplemental Nursing System.  Babies learn to breastfeed by breastfeeding, not cup feeding or finger feeding or bottle feeding. Of course, you can use your previously expressed milk to supplement. And if you can manage to get it, banked breastmilk is the second best supplement after your own milk. With a lactation aid, the baby is still breastfeeding even while being supplemented, and isn’t it breastfeeding you wanted for your baby?

5. If you are having trouble getting the baby to take the breast, come to the clinic as soon as possible for help.

Producing Breastmilk:
As soon as a baby is in sight, contact a breastfeeding clinic and start getting your milk supply ready. Please understand, you may never produce a full supply for your baby, though it may happen. You should not be discouraged by what you may be pumping before the baby is born, because a pump is never as good at extracting milk as a baby who is sucking well and well latched on. The main purpose of pumping before the baby is born is to draw milk out of your breast so that you will produce yet more milk, not to build up a reserve of milk before the baby is born, though this is good if you can do it.

If you know far enough in advance, say at least 3 or 4 months, treatment with a combination of oestrogen and progesterone (as in the birth control pill, but without a break, or oestrogen patches on the breast plus oral progesterone) plus domperidone will simulate the hormonal milieu of pregnancy somewhat, and may allow you to produce more milk. Get information about this protocol from the clinic.

a. Pumping. If you can manage it, rent an electric pump with a double setup. Pumping both breasts at the same time takes half the time, obviously, but also results in better milk production. Start pumping as soon as the baby is in sight, even if this means you will be pumping for 4 months. You do not have to pump frequently on a schedule. Do what is possible. If twice a day is possible at first, do it twice a day. If once a day during the week, but 6 times during the weekend can be done, fine. Partners can help with nipple stimulation as well.
b. Domperidone. This drug can help you produce more milk. It is not necessary for you to use in order to breastfeed an adopted baby, but it will help you develop a more abundant milk supply faster. There is no such thing as a 100% safe drug. If you do decide to take it, the starting dose is 30 mg three times a day, but we have gone as high as 40 mg 4 times a day. Using pumping and domperidone, most adopting mothers have started to produce drops of milk after two to four weeks.

But will I produce all the milk the baby needs?
Maybe, but don’t count on it. But if you do not, breastfeed your baby anyhow, and allow yourself and him to enjoy the special relationship that it brings. In any case, some breastmilk is better than none.

Please note: If you decide to take the medications (the hormones and/or the domperidone), your family doctor must be aware of what you are taking and why. Significant side effects have been rare, but that does not mean they cannot happen. Your doctor needs to be following you, and once the baby is with you, your baby’s doctor needs to know that you are nursing him and needs to follow the baby’s progress just as s/he would any other baby.

Always consult your health care professional and ensure your baby is gaining weight accordingly.

Yes its true! Adopting mothers can breastfeed.  Barbara Wilson-Clay, BS, IBCLC tells us how.

Down through history, a traditional way of nurturing and nourishing orphans has been for another woman, often a relative, to put the baby to breast. Sometimes the adoptive mother already was lactating, but if not, the infant’s sucking would bring in a milk supply. The process of breastfeeding an adopted baby is called induced lactation. Research has shown that breastfeeding enhances bonding. Parents are thrilled to learn that their chosen baby can receive some of the wonderful health benefits provided by human milk, including experiencing the interactions which foster attachment between mother and child.

How does induced lactation work? Simply put, sucking stimulation causes the breasts to make milk. In the non-developed world, most women who are inducing lactation simply put the infant to breast and practice very frequent breastfeeding and baby-wearing (holding the infant almost constantly in a sling or carrier).  In developed countries, where adoption is more likely to be a planned event, the process of induced lactation ideally begins before the baby arrives. The mother starts by manually and mechanically stimulating her breasts and nipples using a combination of gentle massage and a rental grade electric breast pump.

The stimulation schedule typically starts with several minutes of massage and pumping several times a day. Gradually, the woman increases the amount of stimulation until she is pumping for 10 minutes 8-10 times during each 24-hour period. (Pumping on a dry breast may pull some. Try lubricating the pump flange with a thin coat of cooking oil to make it more comfortable.) After massage and pumping are begun, medications may help stimulate the breasts to further increase milk production. Some induced lactation efforts begin with physician-prescribed hormones (estrogen and progesterone) that imitate the hormone levels of pregnancy. These medications are withdrawn after a short while, tricking the body into sensing that a baby has been born. The woman may then begin taking another prescribed drug called a galactagogue (a term that means a milk stimulating substance). Although there is no research to confirm effectiveness, some women who don’t want to use hormones may use herbal galactagogues such as fenugreek in addition to pumping and breast massage to help establish milk production. Within a week of beginning the process most women are very excited to discover that they are producing drops of milk! They may notice other changes. Their breasts may feel heavier and the areolae (the skin around the nipple) may darken. Some woman will eventually stop menstruating.  While the milk supply typically builds over time, it is hard to tell how much milk an adoptive mother will make. Some women eventually make enough milk that they can wean their babies off of supplements. Other women have health issues that may affect their ability to make a full supply of milk. No matter. Any amount of milk is of great value to the baby, but the focus should be on the nurturing experience.

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 www.thebirthden.com/Newman.html) 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.

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”

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