Author: Julie Matheney

Feeding babies has been my passion since I was ten years old. Almost twenty years ago, I pursued becoming a speech therapist to work with babies in the Neonatal Intensive Care Unit. In working in that setting, I realized I wanted a more intimate approach to working alongside families as they struggled to feed their babies. I became a board certified lactation consultant and have really fallen in love with what I do. There’s nothing better than empowering families to reach their feeding goals, wherever they are in their journey, whether it’s exclusive breastfeeding, combo feeding, pumping or bottle feeding. I offer prenatal breastfeeding classes, virtual, office and home consultations. I can assess for tongue or lip ties, educate on pumps to maximize pumping sessions, transition baby to bottle in preparation for parents going back to work, help increase or decrease milk supply, and assist with all breastfeeding challenges.

My baby is refusing the breast: breastfeeding aversion

- Julie Matheney

Aversion to feeding means screaming or crying when offered the breast or bottle, refusing to eat, or needing to be fed while moving or while drowsy/asleep. This is not a temporary nursing strike where baby refuses the breast/bottle for a few days because of periods returning, mom going back to work, teething, or illness, etc. The behaviors seen in baby are much more extreme for a true aversion. Most common causes: 

👅Tongue tie: One of my biggest red flags for tongue tie is reflux and shutting down during breastfeeding (sleepy on the breast, popping on and off, refusing the breast and preferring the bottle but then shutting down on the bottle). Some babies with tongue or lip tie do fine for the first few months by compensating on a full milk supply. The aversion comes around 3-4 months when supply regulates. Address the ties and do oral motor exercises to strengthen the system and the refusal can go away. 

🥛Intolerances/Allergy: This looks similar to reflux, but often with bowel issues as well (constipation, diarrhea, or mucousy/foamy poops). Babies who’s digestive tracts are uncomfortable don’t want to eat. They learn quickly to associate feeding with pain, so they shut down on feeding.

🤮Reflux: Easiest culprit to blame and mask with medication. The medication may mask the pain but won’t actually take the reflux away. Reflux is usually caused by food allergy/intolerance, gut issues, or tongue tie. Address the issue, resolve the reflux. 

🥵Silent aspiration: Milk going into the lungs instead of to the stomach.

🤯Behavioral: The number one concern of parents is feeding the baby. When feeding isn’t going well, it causes extreme stress, which can causes parents to do extreme things to try to fix the problem. It’s easy to spiral out when you’ve tried everything and it’s not working out of stress and desperation. Occasionally the reason for the refusal is no longer there, but it was so stressful in the moment, the panic that it could happen again sets in and perpetuates the problem. Some times the root issue is still there, but you’ve compensated and it’s causing a behavioral manifestation in both you and the baby. 

I don’t like breastfeeding, it makes me feel sad or angry.

- Julie Matheney

Ready to find out more?

You’re not alone if you’re experiencing some kind of breastfeeding aversion. Click here to learn more.

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Breastfeeding is not all snuggles and cuddles. Some may actually experience an aversion to the act of breastfeeding. There are 3 types of aversions:

Sensory Aversion

Breastfeeding is a complex sensory experience full of touch, sound, smell, and movement. This is an aversion to the actual act of breastfeeding. While the baby is latched, mothers experience creepy crawling or tingling sensations in various parts of the body (especially legs), feeling overwhelmed, have an intense desire to unlatch, itching accompanied by intrusive thoughts. As soon as baby unlatches the sensations go away, but often leave a feeling of guilt or sadness for having felt that way. Some of those who identify as neurodiverse or who have ADHD may have higher sensitivities and become more easily overstimulated or overwhelmed by the process of breastfeeding than others. While other people may actually find that it calms and relaxes their sensory system.

Dysphoric Milk Ejection Reflex (DMER)

This only occurs during the actual let down and is a physiological response to the release of the hormone oxytocin. An intense, transient dysphoria results in feelings of dread, anxiety, sadness or irritability, felt for 30 seconds to 2 minutes while the hormone is released. the rest of the breastfeeding or pumping session is totally fine. 

Breastfeeding Aversion and Agitation (BAA)

In further contrast to D-MER, this aversion occurs unexpectedly for some who have previously breastfed for some time. It varies in onset, severity and duration. Those who experience this describe it as involuntary, overwhelming sensation of aversion in response to the act of breastfeeding or pumping lasting the majority of feeding, not just during let down. They experience negative emotions including anger, rage, agitation and irritability. There is a strong urge to run away due to feeling trapped by feeding. (Yate, 2017).

While most people who have BAA describe the feelings and thoughts in a similar way, BAA happens in varying degrees and durations and the onset and severity are unpredictable. This is different then D-MER where the feelings are only during let down. And the feelings during BAA are different than D-MER: anger and agitation are not the same as dread, despair or sadness.

We don’t know what causes it. Hormones, lack of sleep, unrealistic expectations and not enough self care may play a role? There is not enough research on BAA to know how many breastfeeding people it affects, why it happens, and what can be done to treat it. But if you experience this, you are not alone.  Distraction for the breast feeder, taking certain supplements, and peer-to-peer support may help. www.breastfeedingaversion.com

Up to 85 percent of us will experience the some severity of the baby blues.  It is normal to not be happy all the time, especially when transitioning to such a drastic life stage where a tiny human is completely dependent on you for all cares on top of a lack of sleep. You may feel happy one minute and overwhelmed and crying the next. If symptoms are severe or last for more than two weeks, a new mom should be concerned about a postpartum mood disorder, such as postpartum depression. Women who had anxiety or depression before giving birth are at higher risk. The signs and symptoms of postpartum depression include:

* Anxiety

* Sadness

* Anger and irritability

* Difficulty sleeping

* Intrusive thoughts (which may include thoughts of harming the baby)

Next steps:

💡 Know that what you’re experiencing is real and not just made up. You’re not alone in your aversion and there is support!

🍎 Nutrition and hydration are critically. Breastmilk is high in water, which is taken from your blood. Staying well hydrated is essential for not only making milk but also reducing feeling of depletion and aversion while feeding. Drink a glass of water 10-15 minutes before breastfeeding/pumping.

Be mindful of any nutritional deficits you may have, as this can make symptoms worse. Having lab work to determine if there are iron, vitamin d or b deficiencies can help. Many find taking A magnesium supplement may also reduce symptoms. Magnesium glycerinate is the preferred type of magnesium. Magnesium citrate is more common for constipation.

🛌 Sleep is the hardest to get,  but many find their aversion is worse without good sleep. Take any opportunity for a quick snooze

📺 Distract yourself. Watching Tv, using noise reducing or Loop headphones, listening to music or talking on the phone works because your brain can't process both the activity and attending to the emotions/thoughts

🧬Hormonal shifts caused by pregnancy, bf, and periods can throw even the most mindful person off. A blood test can check for abnormal hormone levels of LH, FSH, prolactin, estrogen, and progesterone. Diet changes, specific supplements, or medications can help under the guidance of a trained health care professional.

🛑 Time to wean. It’s absolutely OK to stop if you’re experiencing aversions. As long as you’ve reached your goals and are feeling well supported in your journey

Why does my newborn feel like they’re biting me?

- Julie Matheney
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When a baby latches to the breast, the baby needs to cup the tongue around the niple, keep the tongue out over the gum line, and shape/form the nipple in the mouth while using the lips to seal the cavity to prevent milk from spilling out. This whole progress creates negative pressure, or a vacuum, in the mouth. The tongue then pumps to compress the breast to remove milk. In reality it’s quite the complicated process!

It’s the up and down pump action of the middle of the tongue that is essential for creating a vacuum (negative pressure) inside the mouth for baby to efficiently move milk from the breast. Babies need to be able to protrude the tongue out past the lower gum line AND MAINTAIN IT protruded for the duration of the feeding.

Many parents who have a tongue tied baby will describe breastfeeding with words like “pinch, chomp, bite, and gum”. OUCH. That is because a tongue without full range of motion can’t do these two actions: up and down and SUSTAINED out. If a health care provider told you your baby doesn’t have a tongue tie because baby could stick their tongue out, that single action is not enough. A full assessment makes sure the tongue can stay protruded to cup the nipple and not flick back after every few sucks. This flicking back is what causes the “chomp” or “gumming” sensation. If the middle of the tongue is restricted, that is where baby cannot generate and maintain the negative pressure in the mouth to be efficient at expressing milk. That is why many of those babies fatigue and are sleepy at the breast, feed for a really long time and then are still hungry. They often doing better on a bottle where they only have to compress the nipple to get milk (you don’t need the vacuum seal in the mouth on the bottle to still express milk and when you can’t maintain the seal that’s where the milk leaks out of the mouth).

Think your baby has a tie but you’re not sure what to do next? Consider taking my Tied & Untied class. Click here to enroll

Need some exercises NOW to help your baby’s tongue? Hop over to my YouTube channel for many videos on helping your baby learn to use their tongue. This VIDEO helps baby’s tongue move in all the right directions and can help get your baby ready for a tongue tie release.

Ready to find out more?

There are many informational videos on my YouTube channel to help on the next stage of your journey.

Click Here

My postpartum breasts don’t feel as full, am I losing my breast milk supply?

- Julie Matheney
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Breasts are made of a network of ducts, covered by a layer of fatty tissue. During pregnancy, estrogen and progesterone enlarge the milk ducts and multiply the glandular tissue that produces milk. After birth, estrogen and progesterone drop and prolactin and oxytocin rise. Prolactin makes milk production and oxytocin releases it into the ducts. Extra blood and fluid fill the breast just after birth to supoort your body adding hormone receptors in the breast to make milk. The blood and fluid surrounds the ducts and this extra pressure is what makes your breasts feel full between feeding. This blood and fluid reabsorb around 6-8 weeks once supply is established and you won’t feel that full/soft feeling except when you go a really long time between feeding or pumping. Breasts go back to prepregnancy size when supply regulates around 11-14 weeks but continue to make milk. When you wean from breastfeeding, it can take several months for prolactin levels to return to baseline (which is why you may still see milk for months after weaning). Once you stop breastfeeding, the milk making structures actually self-destruct – a process that involves massive cellular suicide, and the removal of the debris. Around 6 months after weaning, the milk-producing tissue is replaced with fatty tissue. If you return to your pre-pregnancy weight, your breasts most likely will return to the same size. They may not be as “perky” because the skin is a bit more stretched and the connective and fatty tissues in the breasts often shifts during pregnancy and breastfeeding. While they may look smaller after weaning most of us can expect that our breasts will return to a similar size as they were pre-pregnancy. They’re just a little more lived in and well loved.

 

There are two types of engorgement during breastfeeding.
🌞Primary engorgement occurs in the first week after birth. Hormones shift from pregnancy driven to breastfeeding driven.
🔆Breasts may feel lumpy/bumpy or hard as rocks.
🔆They may feel hot to the touch and you’ll often see visible veins on the surface of the skin.
🔆They can increase up to two cup sizes (or more!!).
🔆Breastfeeding or pumping makes the breasts soften.
🔆This marks the transition from colostrum to mature milk and typically lasts 12-48 hours if baby is frequently, efficiently breastfeeding
🔆Heat, massage, hot showers, hand expression and frequent, efficient feeding are the best to help with this transition
⏰Once your milk supply starts to regulate, around 6-8 weeks, you’ll no longer feel as full between feedings and the veining and huge breast size will go away. Around 10-12 weeks your breasts will transition back to prepregnancy size and you’ll no longer feel engorged between feedings at all.

🌚Secondary engorgement can happen at any time during your breastfeeding journey but usually when:
🌐Weaning
🌐Poor latch or inefficient feeding
🌐Change in feeding schedule
🌐Mom unable to pump frequently enough while away from baby
🌐Sleeping longer than normal
⏰Cool compresses before to help reduce swelling, hand expression, reverse pressure softening, gentle lymphatic drainage massage, emptying the breasts regularly and temporarily using cabbage leaf compresses can be helpful. If you can reduce the engorgement, schedule an appointment with an IBCLC to help.

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I have a gassy baby. How can I help?

- Julie Matheney

 

Babies are gassy, fussy creatures. Did you know the majority of babies pass gas 13-21 times a day? Did you know most adults fart 5-15 times per day? Come on, admit it. You’ve passed a few SBDs in your day. Our digestive tracts are sensitive and impacted by what and how we eat. Before you reach for the baby gas drops and probiotics or trying major elimination diets, though, try these things first:

⭐️ TUMMY TIME. This puts baby on their belly which helps stimulate healthy movement through the digestive tract. 

⭐️ BABY WEARING. Having baby in an upright position with legs in a froggy position also helps with stimulation of good digestive movement 

⭐️ SMALL FEEDS. Smaller, more frequent meals can be easier for some babies to digest than larger, less frequent meals

⭐️ DEEP LATCH. Make sure to get a deep latch every time. Shallow latches where you can hear clicking or breaking of the suction during swallowing increases air in the gut. If you see a dimple in baby’s cheek that’s an indication of a shallow latch

⭐️ TONGUE TIE REVISION. When a baby can’t move their tongue correctly or fully they swallow more air. Tongue ties are one of the major culprits of gas, reflux and colic. Having the tongue released in many cases reduces babies reflux and gas 

⭐️ BURP BABY. Some times just being patient to burp the baby well can eliminate wind. After all, farts can just be butt burps

⭐️ MASSAGE. Giving baby a nice belly massage can also help soothe and relieve gas. 

How many times a day does your baby fart?

 

For my full YouTube video showing how to help your baby CLICK HERE



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ADHD and Breastfeeding

- Julie Matheney

For me, being a parent with ADHD means being easily over stimulated by all the noise and energy. I get easily touched out where I want littles off my body. I’m easily distracted and will start one task only to find myself immersed in a less important task and never finished the first task. 

 

I have always been able to hyperfocus on tasks. It made me a work horse in my hospital job with the ability to tune out beeping monitors and nurses and patients talking around me. It is exceptionally helpful when writing social media posts and blogs. As a parent, this tendency gets in the way because there are more important things that need to be done but I get stuck in the loop. During hyperfixation I easily lose track of time and sometimes the ability to prioritize other tasks. Snapping out of hyperfixation is difficult and then everything that needed done gets rushed or put off until later. Always later. And some times when I’m hyper-focusing on a task, I won’t hear my kids until they escalate or crying or whining.  

 

Those with ADHD have an additional work load while breastfeeding. Often undiagnosed and misunderstood in women, those who are breastfeeding will experience additional challenges such as:

🤯Sensory overload: being easily touched out during feeding. Finding the noises and energy of the baby to be very draining and tiring. 

⛓Feeling restricted or trapped by feedings

⏱Time blindness: easily losing track of time during and between feedings

🙀Distracted by tasks, difficulty completing tasks, starting one task only to find yourself sucked into a less important task. You go to wash pump parts only to find yourself rearranging the glass cupboard. 

😵‍💫Overwhelming thought, swirling thoughts, easily anxious. This can have many impacts including inhibiting let down when feeding and reducing the ability to sleep when woken during the night for night feedings. 

 

🤱🏽 Breastfeeding was the easiest part of parenting. It was an excuse to sit in one place and have baby quiet for a long period of time. It meant an excuse for ignoring other tasks because I was feeding the baby. 

🥳Starting something and getting distracted, leaving half done tasks. Folding laundry and fixating on rearranging the sock drawer. Going to put the dishes in the dishwasher, setting them by the sink, cleaning the counter instead because there’s crumbs. 

🤫Listening is hard. I want to listen to my husband and kids, but I often find myself thinking about a million other things. Some times to the point of completely blocking out what they’re telling me.

🧐Hyperfocus. I have always been able to hyperfocus on tasks. It made me a work horse in my hospital job with the ability to tune out beeping monitors and nurses and patients talking around me. It is exceptionally helpful when building social media with posts and blogs. As a parent, this tendency gets in the way because there are more important things that need to be done but I get stuck in the loop. During hyperfixation I easily lose track of time and sometimes the ability to prioritize other tasks. Snapping out of hyperfixation is difficult and then everything that needed done gets rushed or put off until later. Always later. And some times when I’m hyper-focusing on a task, I won’t hear my kids until they escalate or crying or whining.  

🤯Overstimulated. Before kids, I didn’t think I was sensitive to noise and energy. I was the extrovert who loved being around people. But kids are a different kind of energy, especially while also working full time. There’s no downtime or escape from the energy and it’s very draining to the point of meltdown. Getting overstimulated and feeling sensory overload is a very common feeling for those with ADHD.

 

When considering ADHD medication use during lactation, while most medications are considered safe for mom and baby, there is no “zero risk” option. However, the benefits of using a medication to help decrease anxiety and increase focus usually outweigh the risks. If you have been on a certain med prior to breastfeeding and it worked well for you, it would be reasonable to resume that medication while breastfeeding.

 

When taking any medication, you want to monitor for side effects both in you and the baby. Most common side effects when taking ADHD meds are:

🥛 Changes in milk supply

🛌 Sedation/sleepiness or agitation/hyperactivity in baby

⚖️Poor feeding or weight gain in baby

 

Stimulants and non-stimulants for ADHD can work well to help you feel balanced again. Work closely with an IBCLC and your primary care physician when resuming or starting a medication to help continue and feel supported in your breastfeeding journey 



Best Bottle for the Breastfed Baby

- Julie Matheney

Don’t fall for the marketing. There are so many bottle systems out there that are marketing themselves as “just like the breast” and even “shaped like the breast”. In truth the ones that look like a boob often function the least like it.  The good news is there are some really good bottles out there that even though they don’t work LIKE the breast, they can PROMOTE a latch similar to it to help baby go back and forth between the two.

There are many bottles marketed as “most like breast.” The bottle part may “look” like a breast, but the nipple typically has a wide neck and and short nipple, which is how some nipples look like at rest before a baby latches. I call these shoulder nipples. The baby tends to latch just to the short nipple in a straw-like latch because they can’t latch deeply to the wide base (breast tissue expands and fills baby’s mouth, but the rigid silicone of the bottle nipple doesn’t). If baby’s lips are super rounded and there’s dimpling in baby’s cheeks while they suck, they are in a shallow latch. They may still pull milk from the bottle, but this shallow latch back at the breast results in painful nipples and leas efficient feeding. 

 

Want to learn more? Take my Latched class to help find the right bottle for your breastfed baby.

CLICK HERE TO ENROLL

 

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Bottle nipples that have a more gradual slope from tip to base and a cylindrical shape are preferred for all babies, whether breastfeeding or not. Why cylindrical? We want your nipple to go in and out of baby’s mouth round. If your nipple is coming out pinched, creases, or flat, we’re talking about improving a shallow latch or releasing a tongue tie. Bottle nipples that are lipstick shaped, flat, creased, or pointed are going to promote incorrect sucking patterns which can transfer back to breast. Now hear me on this: while a round, tapered nipple are optimal, there are times when a different shape nipple is appropriate, especially if they’re the only shape baby will successfully take. We want all babies to have a wide latch to the bottle for more efficient feeding and better use of their facial muscles for skill development. I usually prefer the narrow neck to the wider versions for the majority of babies, as it helps promote better lip flanging, although some babies they will do just fine on the wider version. If your baby is struggling to take a round, tapered nipple, please seek the help of a qualified and specially trained IBCLC lactation consultant, occupational or speech therapist. CLICK HERE TO BOOK WITH ME NOW

 

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When a baby is at the breast, they create a vacuum in their mouth with negative pressure by making a seal with their tongue to the palate. They then use positive pressure by compressing the breast as their tongue moves in a wave like pattern from front to back called peristalsis. Positive and negative pressure are essential for a baby to efficiently feed from the breast. They need to maintain the tongue protruded over the bottom gun line and in that vacuum seal through the duration of the feeding, and the middle of the tongue needs to pump up and down to help compress out milk. This is why babies with tongue ties can struggle to feed both breast and/or bottle. Bottles work totally different than the breast and many only need the compression piece for baby to move milk. Some bottle nipples do a better job of approximating the breastfeeding latch and do require more suction in order to remove the milk. In general, bottles that require a combination of suction and compression to remove milk better promote breast feeding by using a more natural and functional sucking pattern. Those systems that use compression only promote a chomping sucking pattern or the baby squeezes the nipple harder to move milk, which can make it difficult (and painful) when transitioning back to breast.

What nipple “level” should my baby take? Nipple flow levels are not standardized across the bottle industry. Each company has their own set rate and it is completely different from company to company.  A level one will flow simple tell different across every brand of bottle. What is “slow” on one nipple can be very fast compared to “slow” on a different nipple. Britt Pados has done multiple research studies that measure flow rates. Turns out there are some brands “Slow” that are actually faster than other brands “Level 3” . Remember: don’t fall for the marketing. If your baby is coughing, choking, leaking milk or struggling to drinking from a nipple, try going to a slower flow nipple in the same brand and if that doesn’t work, switch brands. Do you ever need to go up a nipple level? No. They are marketing nipple levels by age like Carter’s does with onesies. If it fits, use it. No need to level up if your baby is content. Ever.

From a lactation perspective, we generally want breastfed babies to use a nipple that matches the flow of their mothers milk back at that breast. This is USUALLY the slowest flowing nipple (remember, this will vary from brand to brand). We want them to take a bottle slowly since breastfeeding is usually a slow process, and we want them to actively suck to get milk out. Although for those with a fast let down or over supply of milk, it’s totally fine to use a faster flow nipple that matches the speed at which your baby takes the breast.

 

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Babies are masters at compensating to feed. They learn very quickly what works and what doesn’t to get milk. But sometimes this comes at the cost of them compensating with their muscles which can lead to symptoms like lip blisters, two tone lips, lots of gassiness and reflux. Clicking while swallowing, leaking milk, coughing and eating too fast are all symptoms that something isn’t right: either with the nipple shape, flow level or their latch OR something else may be going on in their mouth like a tongue and lip tie. If baby is doing well with their bottle and you have no concerns, keep doing what you’re doing! No need to start fresh and buy new. Some babies do a really nice job of going back and forth from breast to bottle, despite requiring different mechanics. If you are seeing any red flags and something doesn’t feel right about your baby’s  bottle feeding skills, either breast or bottle, schedule a consultation. There is help and guidance for you to get things back on track.

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Ardo Calypso Breast Pump Review

- Julie Matheney
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The Ardo Calypso breastpump is a piston-driven, closed system breast pump. Weighing less than 1 pound, it is a lightweight and one of the quietest breast pumps I’ve used. Vacuum Seal technology ensures no milk can get in the tubing or pump. The piston technology allows the suction to maintain its negative pressure, therefore never releasing the breast and allowing the ability to replicate a baby’s natural nursing action. It does have 64 individual settings, meaning there are multiple cycle and suction options that can be changed into different combinations for individuality. That said, the maximum suction strength and cycle speed are still relatively low compared to other pumps like the Spectra or Limerick, meaning if you need a faster or stronger cycle or suction, this pump won’t get there.  If you have sensitive nipples and trigger let downs easily, this pump is a good option. If you need to feel the stimulation of the pump to trigger your let downs, this is not the pump for you. The Calypso breastpump can operate on 6 AA batteries (rechargeable or standard), a wall power plug, or a car adapter. Another disadvantage is their flanges. They come as a one piece unit in 26 and 31mm sizes. So unless you have extremely large nipples or can use a flange insert, this pump isn’t a good option for getting the right flange fit. You’d need to use the tubing with another flange system if you needed different flanges like LacTeck, PumpinPals or smaller traditional, plastic flanges instead of the inserts.

View their warranty here

  • Closed System
  • Single or Double Pump capability
  • Piston driven suction measuring 250 mmHg
  • Weighs less than 1lb
  • Battery operable or wall plug operable
  • 64 customizable settings on a digital display
  • (1) Year or 400 operational hour Warranty. This is voided if you use other  products, like flanges with it. 

Included:

  • Two Ardo 26mm Breast shells (flanges)
  • Two Ardo 31mm Breast shells (flanges) with 26mm soft silicone inserts
  • Two Ardo Tubing
  • Two Ardo Lip Valves
  • Two Ardo Membrane Pots, and one replacement spare  
  • Multiple Ardo 5 Fl oz Milk Collection Bottles  
  • One Ardo Wall Power Adapter
  • Handle to convert the pump into a hand pump
  • Cooler bag with ice block
  • Carrying bag (which honestly is very nice and sturdy)

Birth control and breastfeeding

- Julie Matheney

There are two forms of birth control. Non-hormonal and hormonal methods. Non-hormonal birth control is any option that does not have a hormone in it. Options include the copper IUD and barrier methods like the condom, cervical cap, diaphragm, sponge and sterilization. Rhythm or calendar methods where you’re tracking cycles and assessing cervicales fluids need to be tracked vigilantly and many will choose to still use an additional method if cycles are unpredictable.

CLICK HERE FOR THE FULL VIDEO TUTORIAL ON BIRTH CONTROL AND BREASTFEEDING

Breastfeeding itself has also historically been considered its own form of birth control. Lactation amenorrhea is nature’s natural family planning to help space out babies. If you are exclusively breastfeeding, no bottles no pacifiers no pumping, and baby is still nursing frequently day and night, often sleeping close to or co-sleeping with breastfeeding parent, where there is no vaginal spotting or a period hasn’t returned yet and baby is under 6 months of age, this form is considered >95% effective to keep you from getting pregnant again. While this is the general rule of thumb, every single criteria needs to be met in order for it to be effective. And even if this is being followed to the letter, some may still cycle again and can become pregnant before a period returns. I’m of the anecdotal opinion that there are many modern influences on why this method doesn’t always work. Prior history of HBC, maternal age, modern diet and lifestyle, may not allow everybody to be able to experience this form of birth control. On the other hand, there is also a small population that never gets a period the entire time they breastfeed and may actually need to wean in order to get pregnant again. This method of bc is not one size fits all and needs to be counseled as such. It is possible to have several light periods without ovulating, giving you a heads up that another form of bc is needed to prevent pregnancy, but it is also possible to ovulate and get pregnant before you have a first postpartum period.

In terms of hormone based birth control, in a nut shell:

  • Hormonal Birth Control (HBC) comes in 6 different delivery systems. 
  • Any HBC runs the risk of decreasing your milk supply. So you’ll want to be careful with the method you’re choosing.
  • The hormone level of each brand in each type of HBC will have its own amount of hormone and they are not equal. So do your research when selecting any HBC, even if you’ve used a particular method prior to your breastfeeding days.

All types of HBC prevent pregnancy effectively but the best method for you will be the one that suits your lifestyle and needs. The most effective HBC will also support any goals you personally have related to breastfeeding.

Hormonal methods of birth control contain either progestin or a combination of both progestin and estrogen. Hormonal birth control options include the pull, the intrauterine device (IUD), the shot, the implant, the ring and the patch. These methods of birth control have high rates of efficacy, but if you choose a method that is difficult for you to use correctly, it could lead to unintended pregnancy. Certain methods also carry a higher risk of decreasing milk supply  

All HBC works to prevent pregnancy by preventing ovulation or thickening cervical mucus to prevent implantation of an already fertilized egg. Many do both. 

The best birth controL is one that works for for each individual’s lifestyle, that can be used correctly and consistently. Knowing what’s available and the risks and benefits of each method can help guide the best choice for your family. In the event you see an impact on your breast milk and need to switch forms to reach your goals, there are also many options. Please also note that hormone based contraceptives are not considered safe for ALL to take and you will want to discuss your unique medical history with your healthcare provider when making any decision about what you are putting in your body.

A small amount of the synthetic hormones in contraceptives will enter your milk and be passed to your baby. There is no evidence in the research that this is harmful to your baby. Some babies younger than 6 weeks may have difficulty metabolizing the hormones and for this reason it is not recommended to start using HBC until your baby is older than at least 6 weeks. Some report after they start taking HBC they notice an increase in fussiness in their babies and many of these same parents report an improvement in the fussiness when they change their method of birth control.

Also keep in mind that no form of hormonal contraception offers protection from sexually transmitted infections (STIs)—but using a condom with a hormonal birth control even further reduces your risk for pregnancy while also protecting from STIs.

Let’s take a look at different forms of hormonal birth control, how they are delivered and how effective they are. 

The Pill

Oral contraceptives are also called “the pill.” Birth control pills have been in use since the 1960s are the most common form of hormonal contraception in the United States. There are three types of pills with different combinations of hormones. The first is the cyclic combination oral contraceptive (COC). People who use this pill as prescribed have monthly bleeding that mimics a monthly period. The second type is the extended use COC pill. When taken as directed, a person experiences less menstrual-like bleeding. This method tricks your body into thinking it’s already pregnant so it doesn’t release an egg to be fertilized. There’s also the progestin-only pill (POP), which is estrogen-free and is often referred to as “the mini pill”. 

The benefits of the pill include it’s rapid reversibility (cycles return within a few months), regulation of menstrual bleeding, decreased menstrual blood loss, decreased menstrual pain, decrease in frequency of menstrual migraine and decreased endometriosis symptoms. Because the hormones in the pill suppress ovulation, its use is also associated with decreased premenstrual syndrome (PMS), decreased ovarian cysts, decreased risk of ovarian cancer and decreased risk of fibrocystic breast changes and cysts.

Birth control pills must be taken daily to achieve the highest level of efficacy. They also have increased potency when taken at the same time every day to maintain hormone levels consistent across time. Research shows that more than half of people using the pill forget to take one or more each month. Both the COC and extended COC pills have estrogen, the hormone that raises during pregnancy and is in opposition to prolactin and oxytocin, the hormones responsible for making and releasing milk. Taking either of these options will drastically drop your milk supply and are not preferred when breastfeeding is the goal. Progestin only pills, called the mini pill, is considered safe while breastfeeding and has the least risk of dropping milk supply. This is the preferred method of contraception while breastfeeding. While the limited research that is out there shows it holds a minimal risk of dropping supply, every body responds differently to hormones, and I have seen some people drastically drop their supply even on the mini pill. The perk of this methods is If you notice a drop in supply you can stop taking the pill and your supply should rebound in the same time frame it took to see it drop. So if you were on the pill for one cycle it will usually only take one cycle to rebound. Many people see no difference in their supply when taking the mini pill but this is why we call it risk assessment.

The Patch

The patch is similar to the pill in that it contains estrogen and progesterone. Instead of taking a pill every day, however, the patch is made of thin plastic that is placed on the skin of the arm, abdomen, buttocks or upper torso and delivers hormones through the skin. The patch should be placed on clean, dry skin and needs to be replaced weekly. Typically, the patch is used for three consecutive weeks, followed by one week during which no patch is worn in order for menstruation to happen. Benefits of the patch include the convenience of once-a-week dosing and a rapid return to fertility for those who stop the method to become pregnant. Some reported side effects of the patch include skin reactions, breast discomfort, headache and nausea. Because of the high levels of estrogen and progesterone, this method is also not preferred while breastfeeding as it runs a high risk of significantly decreasing breast milk supply.

The Ring

The ring delivers estrogen and progesterone through a circular piece of plastic that’s vaginally placed. The  ring is inserted and often left inside the vagina for three weeks, followed by one week during which no ring is used to facilitate menstruation. Some advantages of the ring include rapid return to fertility when pregnancy is desired, convenience of weekly insertion, and the ability to remove it for a brief amount of time (3 hours) without compromising efficacy. Some ring users report vaginal discomfort, and others experience nausea, breast tenderness, or changes in libido. As with some other hormonal contraceptives there may be a risk of blood clots with the ring, but more research is needed. Because of the high levels of estrogen and progesterone, this method is not preferred while breastfeeding as it runs a high risk of significantly decreasing your supply.

The Shot 
The shot is also called the injectable contraceptive. A commonly used version of this contraceptive  contains only  progestin , no estrogen. and is administered every three months. The shot is reversible, but a return to fertility may be delayed until the effect of the last injection wears off. Because the effects of the shot can last up to 3 months, if you are one of the people that does experience a drop in milk supply with any progestin based HBC, you do run the risk of losing the supply and not being able to bring it back up until the effects of the shot wears off. Which means you may need to supplement until the shot wears off and you run the risk of not being able to bring back supply as that is a signficinat amount of time to have a lowered overall supply.

Some people like the shot because it is available without estrogen and is only taken every one to three months depending on the brand. Some other benefits include absent or light bleeding, decreased cramps and PMS symptoms, reduced endometriosis pain and decreased risk for pelvic inflammatory disease (PID) and endometrial and ovarian cancer.

The shot has some potential disadvantages. Bleeding can become unpredictable for some while others may find they don’t bleed at all. There is also a higher correlation of people who get the shot and see and increase in weight, although the research isn’t sure why. More research is needed to determine whether and how the shot impacts mood (people interested in this method but worried about the role of hormonal contraception in depressive symptoms could mention this to their healthcare provider). This is especially compounded in the postpartum period when there is a higher risk of PPD/PPA. People who use the shot long-term can experience a loss in bone density, but it’s generally reversible. The biggest challenge with the shot and breastfeeding is once you’ve been given the shot you can take it back. The hormones are in your system. If you see a drop in your supply you won’t be able to do much about it until the shot wears off. There would be a few, extreme interventions such as herbs, medications, and additional feeding and pumping that may help, but supply is not guaranteed to rebound from this type of drop.

The Implant

The hormonal implant is the most effective form of hormonal birth control. The implant is a thin rod that is inserted under the skin in the upper arm. It lasts for three years, at which point you can return to  your health care provider to have a new rod implanted. The implant is progesterone-only and contains no estrogen. There are several advantages to this type of method: you never need to generate to do anything, its discreet, decreased menstrual pain and rapid reversibility. Because it’s effective for three years, the implant is also cost effective. In research studies, fewer than 20 percent of people have the implant removed early because of side effects.

Insertion of the implant is an in-office procedure that causes a small percentage with this type of HBC to experience some swelling, bruising, and pain. Removal of the implant is also an in-office procedure and usually takes just a few minutes. Some disadvantages of the implant include the possibility of unpredictable bleeding, headache, weight gain, acne and breast pain. Studies are in conflict for whether it lowers libido or improves sexual function. Because it is progestin only, it does have less of a chance of decreasing your milk supply. BUT if you are one that does see a drop in supply with any HBC and you see a drop in supply from this method, only removal of the implant will help increase supply again. Because of this, you might want to trail the effects of progestin only pills before trying this semi permeant method of contraception.

IUD

The IUD is a small T-shaped implant placed inside the uterus. There are two types of IUDS: copper, which doesn’t  have hormones, and hormonal. It must be placed by a healthcare provider in an in-office procedure. Some OBs may push for placement of an IUD at your 6 week postpartum appointment. This is because the cervix often hasn’t fully closed since delivery so it is easier for your practitioner to place. The IUD is highly effective. It doesn’t contain estrogen, is a one time placement that you can forget and not need to have placed multiple times, discreet, rapidly reversible, long lasting and has high rates of satisfaction among those who have one placed. Hormonal IUDs come with differing doses of hormones and the length of their use varies from three to seven years based on each brand. This is important to consider. The higher the level of hormone in the IUD, the higher the risk it will cause a drop in your supply. The Mirena and Liletta have 52mg and the highest amount of hormone. The Kyleena has 19.5mg and Skla has 13.5mg. The paraguard, which is made of copper has 0 hormones and will not impact milk supply but carries the same other risks of IUDs.  If you see a supply drop, there is not much you can do to regain that milk as this is reproductive hormones impacting breast milk hormones.

Some potential disadvantages include unpredictable changes in period cycles, cramping at the time of insertion, and some concerns about weight gain. In rare cases, pelvic infection can happen after insertion.  Occasionally they have also “fallen out,” or people have pulled them out accidentally. There is also a rare but possible chance that it will perforate (poke through) the wall of the uterus. If the IUD is the culprit for decreasing your milk supply, depending on your breastfeeding goals and how significant the drop is, some will consider removing the IUD.

There is no way to predict how your individual body will respond to a HBC, even if you used it prior. Depending on the importance of the breastfeeding goal vs risk of pregnancy,  I always counsel my patients to consider trying a round or two of the mini pill prior to IUD insertion. If they do notice a drop in supply, stopping the pill and using a different method of non hormonal contraceptives may help them reach their goal for breastfeeding. Other families will assess the risk of pregnancy vs breastfeeding vs formula and if there is a supply drop, supplement with formula to whatever level is needed. This decision is one that only you and your partner can make and the options need to be weighed based on your unique lifestyle, family planning and breastfeeding goals.

ABM Clinical Protocol #13: Contraception During Breastfeeding. Breastfeeding Medicine. 2015 https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/13-contraception-and-breastfeeding-protocol-english.pdf

Daniels K, Abma J. Current Contraceptive Status Among Women Aged 15–49: United States, 2015–2017 [Internet]. Available from: https://www.cdc.gov/nchs/data/databriefs/db327-h.pdf

Hatcher RA, Trussell J, Nelson A, Cates W, Kowal D, Policar M. Contraceptive technology. 20th ed. Ardent Media; 2012.

Goulding Alison N., Wouk Kathryn, and Stuebe Alison M., Contraception and Breastfeeding at 4 Months Postpartum Among Women Intending to Breastfeed. Breastfeeding Medicine. January 2018, 13(1): 75-80.

Birth Control

U.S. Selected Practice Recommendations for Contraceptive Use, 2016, K. Curtis et al, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion

 

Picking a breast pump: vacuum considerations

- Julie Matheney

What do I need to know about picking a breast pump? Suction/Vaccum

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You would think that a stronger breast pump is better. But before you put that breast pump on the highest setting, make sure you know the benefits (and risks) of using the highest strength setting. Breast Pump power of suction is usually documented as mmHG which is millimeters of mercury, the standard unit of measuring vacuum pressure. Studies were done on babies sucking at the breast and breasts pump suction levels are based off what we know of how babies remove milk from the breast. The suction level, or vacuum, is DIFFERENT than the cycle speed, which is how fast it pumps. This is why breast pumps should have two settings that should be changeable: cycle (speed) and vacuum (strength). Most pumps will cycle 40-70 cycles per minute. This is based off of the average number of sucks a baby does at the breast in that same amount of time.

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Breast pump effectiveness is evaluated by measuring the vacuum (also called suction) of the pump with a pressure gauge, an instrument that measures negative pressure. The gauge needle points to a number from 0 to 450 mmHg (the abbreviation for millimeters of mercury – Hg is the chemical symbol for mercury).  The gauge measures the vacuum, not the speed, of the pump. When there are questions about a pump’s performance, the concern is usually about the vacuum, but not always. Each breast pump has been manufactured to have specific pressures based off that unique pump. When assessing different pumps, the reading on the gauge is then compared to a standard range for that individual breast pump that is being tested, to determine whether the pump is performing per manufacturer’s guidelines or not. When you purchase a breast pump, the mmHg the pump has a capacity to reach may be in the product listing or manual. This number is important to pay attention to. Based on known research for the vacuum babies can generate a that the breast to remove milk, the pressure leves should be in the range of 220 to 350. The number is the maximum suction level that specific pump can achieve. “Hospital grade” pumps generally have maximum suction levels in the 300 range while personal grade pumps are generally in the 200 range. This doesn’t necessarily make a pump better or worse. Hospital grade pumps typically have bigger, stronger motors as they are physically bigger pumps. They are also multi-user pumps that need to have a longer shelf life for use.

Interestingly enough, vacuum levels can vary based on weather (so do not test pumps during stormy conditions) and elevation. Maximum pump vacuum values are set at sea level. The higher you are in elevation, the lower the maximum suction strength your vacuum with achieve!

Breast pump suction is supposed to mimic baby's natural sucking through several phases:

  • Let Down - mimics when baby is vigorously sucking at the very beginning of the feeding and in order to try to stimulate additional let downs during the feeding. Babies can trigger any where from 2-9 let downs in a feeding. This phase stimulates the nerves in your nipples, which signals the release oxytocin, the hormone responsible for letting down your milk. The release of oxytocin contracts the small muscles that surround your milk-producing tissue, which squeezes milk into your ducts and down to the nipple which is then removed by the baby. Many babies will stay in this vigorous sucking phase for up to 1-2 minutes or until they trigger your let down.
  • Expression - this phase is when baby's sucking slows down, and he/she is swallowing the remove all the milk that was let down from the breast. Many babies stay in this phase for 4-8 minutes, the time it takes to “reset” your hormones to trigger another hormone release of oxytocin.

Vacuum suction patterns have been programmed into certain pumps that copy the movements of an infant's tongue with the goal of to reproducing the pattern of how older infants suck. After the first few weeks, babies will typically alternate between a light and fast "flutter sucking" to a deep and rhythmic sucking pattern, and occasionally when flow changes suck with both intensity and speed. By alternating back and forth between similar patterns on the pump, more let downs can be triggered which allows more milk to be expressed.  Pumping with higher strength and efficiency is what is needed to make sure that the body receives adequate signals to increase breast milk volume and to transition from colostrum to mature milk when establishing supply in the immediate days postpartum. This is especially imperative in situations where the pump is replacing direct breastfeeding. This happens when there is a separation from mother and baby in the first week after birth, baby is unable to latch and suck adequately, there is a tongue tie and the family is waiting to have that released, or any other reason why a parent would choose to exclusively pump.

It’s not true that higher pump suction level equals more milk output. The highest suction level on a breast pump are actually above the comfort zone of the majority of pumping mothers. So even if the breast pump has a maximum suction level of 350 mmHg, most will still feel more comfortable expressing in the range of 150 – 200 mmHg regardless of whether the pump can reach 250 or 350 mmHg at its maximum setting. Pumping at too high of a suction level can actually hinder milk flow and even be the root cause of plugged ducts, mastitis, and breast/nipple damage! Think of it like drinking from a juice box straw. With hard sucking, the juice box starts to collapse on itself and not as much juice can move out because of the vacuum effect. You get more juice by gentle, consistent sucking. Milk ducts are small, compressible tubes inside the breast that move milk from milk-making glands at the back called alveoli down to every smaller diameter ducts that empty to nipple pores at the front. Too much breast pump suction compresses the areolar tissues which squeezes the ducts and actually decreases the flow of milk out the ducts. With time this can cause milk to back up in the breast, increasing the risk of plugged ducts. This can also foster inflammation and risk damage.

So why do you feel like you need to turn the pump suction all the way up to move your milk? The number one reason I see for this is because you’re actually using the wrong side flange/breast shield. The majority of people cannot pump with the flange that comes in the box. The 24mm flange was standardized many years ago and hasn’t changed much with time.  In my experience, the majority of the people I work with need to size DOWN, and often significantly. When the flange is too big there is too much air space in the tunnel and a higher vacuum level is needed to generate enough change in the negative pressure in the flange to move the breast tissue. By finding the correct flange fit, less vacuum is needed to effectively move milk and the entire pumping experience is more comfortable.

It’s impossible to know ahead of time which cycle and suction settings will work best for your when you start using a breast pump. Everyone’s anatomy is unique and their sensitivity to the pump is individual. What works for one person may not necessarily work for the next. Those with nipple sensitivity may need a softer, gentler pump that cycles slower and with less vacuum. Other many have larger breasts with longer nerve pathways from the nipple that need higher suction and speed to stimulate let down.  When considering a breast pump, the most important thing is having a pump that gives you the most flexibility to adjust cycle and vacuum settings to find what works to trigger your milk.

If you’re buying a hospital grade breast pump because you know you’re going to be frequently pumping at work or exclusively pumping, look for a maximum vacuum strength above 300 mmHg. Most hospital grade breast pumps on the market will top out at 320 – 350 mmHg. If a breast pump is marketed as hospital grade and the maximum suction level is listed at below 300 mmHg, you should look more closely at the technical specifications and compare them to other hospital grade breast pumps on the market before buying it. If you’re buying a personal grade breast pump, look for a maximum breast pump suction level of 250 – 300 mmHg. The majority of personal grade electric breast pumps on the market fall within this range. If the vacuum strength tops out at below 250 mmHg, it usually means a weaker motor. This may still stimulate a small percentage of pumpers, especially in the early days postpartum when it is easiest to trigger let downs, but may not be strong enough for long term pumping. You should look more closely at the technical specifications before buying a breast pump like this, because a weaker motor means the motor has to work harder to perform at the same level as other personal grade breast pumps. These pumps also wear out faster and the motors don’t work as well for as long.