Human milk changes in its composition throughout lactation as your baby grows and is constantly changing to meet the needs of the baby from the first few days of colostrum to beyond the baby’s second year. The composition of your milk can change from day today especially as hormones ab and flow with your menstrual cycles. They can change during a given day based on your stress levels, how often your baby feeds, and how well your baby MDs your breast. But did you know that the composition of your milk can also change during an individual feeding and from breast to breast?!?! As the baby eats, protein and fat content rise in the milk. There is actually 4 to 5 times more fat and 1 1/2 times more protein present at the end of the feeding than at the beginning. The baby may consume nearly 18% of their calories between minutes 11 and 16 of a feeding. The fat content at the beginning of a feeding is around 1% milk fat. By the end of a 15 to 20 minute feeding, the fat content can be as high as 4 to 5%! By comparison, whole milk contains just 3.25 percent milk fat. Fat content varies from mother to mother and from feeding to feeding. The amount of fat in breastmilk is dependent on the length of time between feedings, the degree of breast fullness, and the length of time the baby sucks at the breast. To put it simply, the emptier the breast, the higher the fat content. The fuller the breast, the lower the fat content. By trying to “stretch” a baby to scheduled feedings actually decreases the fat content in a mothers milk. It is always best to feed baby on demand.
Fact of the day: Human milk has one of the highest levels of lactose among mammals: 7%. Lactose accounts for almost all the carbs in breastmilk and provides 40-50% of the energy in the milk. Lactase is the enzyme naturally produced in the body to convert lactose into simple sugar. This enzyme is prevalent in our bodies at birth but it’s production lessens after age 3. Up to 70% of the world’s adult population has a lactase deficiency, which is indicative of the body maturing and no longer needing human milk as the primary source of nutrition. It is rare for children under 3 to have lactase deficiency, reflecting the biologically normal age for weaning.
As mamas we all have the same fear: are we making enough milk to keep our tiny humans alive? In the pumping room at work I get this question in all of its forms multiple times a week. With the advent of formula feeding, we have even more question and doubts about our body’s natural ability to produce for our offspring. First of all, we need to stop comparing breastmilk to formula. They are not the same. No matter how good the marketing is, formula can never compare to breast milk. Breast milk is a living, changing tissue. Formula is static and produced. Did you know formula fed babies take an average of 33% more volume per day than breastfed babies? Why? Because their bodies are only half as effective at processing it than formula. They basically need to eat more to get the nutrients and calories they need for growth. The human body was designed to consume breastmilk, therefore it is the perfect balance of calories, fat, and protein and can be maximally digested and used as fuel in the body.
I was recently contacted via Facebook about my opinions on supplementing at birth when mother’s milk “doesn’t come in right away”. I thought you might be interested in my response. The first several paragraphs are the background anatomy and physiology of early breastfeeding. Below are the questions I was sent as well as my responses. Enjoy!
Breastfeeding is a natural process that has become misunderstood by the general public as it became hidden from the community. I believe when mothers actually understand the process of breastfeeding, it can help then understand what is going on in their newborn. Prenatal breastfeeding classes are essential for this. At 10-14 weeks of gestation, every mothers breast begins to fill with colostrum, a high protein milk which acts as a laxative. It’d why their breast change size during pregnancy. Mothers already have the first milk in the breast that their babies need for birth. It is in a small volume because babies are born constipated and fluid overloaded from the womb. In a natural, uncomplicated delivery, a newborn has a high need to suck because of this constipation. Sucking causes peristalsis (a wave like movement) to travel through the esophagus through the stomach to the intestines to push out the poop. It takes approximately three days for all the meconium to be pooped out (which is exactly how long it takes for colostrum to change over to mature milk!!) Nature designed the breast to feed the need of the baby in perfect balance to allow baby to become unconstipated so the gut would be ready for nature milk at the right time. Breast milk actually doesn’t “come in”. It’s already there in the form of colostrum. The first few days are controlled by the autonomic system. You’re pregnant so you will produce colotrum and your body will think you’re feeding a baby. You need your baby to suck at birth to lay down hormone receptors in the breast for prolactin, the milk making hormone. The more your baby simulates your breast in the first few days after birth, the more hormone receptors are activated to make milk for your baby. After the first few days, you switch from the autonomic system to the demand a supply model that continues for the duration of breastfeeding. The more the baby demands, the more mama makes.
Unfortunately in the modern world of medicine, we have tampered with the natural process of birth and thereby impacting breastfeeding. With IV fluids, the epidural, and other medications used in birth, we’re changing how newborns interact with the world and how hormones in mom are being produced. The epidural rate in hospitals in LA County is over 80%, with many hospitals over 90%! It actually causes sleepy babies that do not do as well at the breast (Richard and Alade, 1990, https://youtu.be/4eQdQ1Ww9-k) Cesarean births also significantly delay the Natural switch from colostrum to mature milk for obvious reasons based on the above information. Babies really need to be skin to skin and at the breast with no interruption for the first few days of life or until mature milk had come in. Skin to skin contact promotes physiologic stability in the baby (including regulation temperature ebooks sugar) while promoting free access to the breast to facilitate the process described above. If hospitals encouraged mothers in Birthing a more natural and unmedicated way, we would actually see a significant drop in the need for supplementation and in breastfeeding issues.
The Baby-friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991, following the Innocenti Declaration of 1990. The initiative is a global effort to implement practices that protect, promote and support breastfeeding. Formula fed babies have a 50% higher risk of dying of SIDS at all ages of infancy with even higher rates in other developing nations due to unsafe water and lack of finances for parents to afford formula. Baby friendly hospitals in the US understand the importance of breastfeeding but aren’t the best at communicating why. Breastfeeding is better for babies for a laundry list of reasons.
One of my newest clients.
What should expectant parents look for when searching for a lactation consultant? They need to find someone who is skilled and trained. An IBCLC is always the gold standard because of the extensive training we go through. Facebook forums are horrible for information because there is a lot of poor information floating around. Yelp is great for reviews of local consultants. If they suspect a tongue tie, they need to find a lactation consultant specifically trained in it. Not every one is.
How are lactation consultants accredited and are their different professional organizations? http://blog.mothersboutique.com/whats-the-difference-between-lc-ibclc-cle-etc/
http://www.lalecheleague.org/faq/lc.html
What is generally the maximum amount of time a mother should wait for milk to come in before offering formula? For instance, after a c-section when it can take longer. This is a loaded question because every story is different. In the hospital it’s always based on bilirubin numbers and the risk for jaundice. In my practice, if a baby has not has the recommended number of wet diapers by day three we’re supplementing at the breast using an SNS at the very least.
What are the guidelines when it comes to (temporarily) supplementing with formula for newborns? Unfortunately there are no guidelines and every practitioner comes from their own experience and setting. There are no rules and it’s a case by case basis which should be based on parents breastfeeding goals, but unfortunately is not always an option.
When waiting for milk to come in, what amount of weight loss would be a red flag? 10% is normal weight loss for all infants. Birth weight needs to be regained by 2 weeks. And we need to know WHY. Is there a tongue tie? Does the mother have a hormone issue? Does the baby have birth trauma or tortícolis? Is there a metabolic issue or heart defect? Is it simply a poor latch or improper position? Did the baby have poor oral skills? These all can relate to weight loss. At what point would you advise a breastfeeding mother to offer formula? If baby gets adequate skin to skin time and constant access to the breast, most of these issues resolve on their own. If a baby is lethargic, sleeping more than 4 hours multiple times in a row, or not making enough wet and dirty diapers by 48-72 hours, I’m all about supplementing. But that’s me coming from a hospital background. I don’t mess around with the risk of jaundice. I also always prefer supplementing at the breast with an SNS and with donor breast milk when possible. Stimulate the breast for increased production while getting the baby fed and used to the breast at the same time.
Do you feel the threat of “nipple confusion,” supply issues, or a mother “giving up” breastfeeding are valid reasons for avoiding formula when milk hasn’t come in? Are there other reasons to avoid temporary supplementing? This is another misconception. There really isn’t “nipple confusion”. It’s actually flow confusion. At the breast, babies need to stimulate milk flow at the beginning of a feeding with active suckling. It can take one to two minutes of suckling for let down to happen. Breasts can flow at different rates and even flow different during a single feeding. Bottles, however, are instant and constant. It’s much easier to feed from a bottle, so some babies “prefer” this from having to work at getting their milk. A lactation consultant can help with any issue of flow at the breast to help with this. Opinions vary in the introduction of a bottle. Some say no sooner than 2-3 weeks or when breastfeeding is well established. Die hard lactation consultants say no sooner than 6 weeks. In NICU where I work, we use bottles from day one and babies easily transition back and forth between breast and bottle. We use and teach paced bottle feedings and use of a slow flow nipple to try to replicate breast flow from a bottle.
What do you think is the biggest benefit to enlisting lactation consultants’ help in breastfeeding? The earlier you get help, statistics show, the longer mothers will breastfeed. If breastfeeding is your goal, get help in the first 72-96 hours. Enlisting help give mothers the confidence in knowing subtle changes in positioning and latch that can make a world of difference. An LC can also identify if there is something wrong, like a tongue tie, inverted nipple, swelling of the breast from fluids at birth, etc that is impacting feeding.
Do you feel pediatricians are being pulled in different directions when it comes to supplementing? For instance, they are promoting breastfeeding because of the proven health benefits, but also want to be able to offer formula because sometimes it’s needed? Pediatricians get a 45 minute lecture on breastfeeding on medium school if there lucky. It depends on their training and setting. They are mostly concerned about weight and usually have no problems supplementing outside the hospital setting. In the hospital, if it is baby friendly, there are guidelines for when formula can be introduced.
What are your thoughts on the “fed is best” campaign? I strongly disagree with it. But I’m in the profession of breastfeeding. The risks of not breastfeeding far outweigh the benefits of formula feeding. There are obviously cases when supplementation is absolutely necessary and mothers should never be shamed of needing to supplement. They should also be encouraged to get professional help as soon as possible to facilitate breastfeeding from the beginning. So many issues can be prevented before they’re a problem.
Do you feel that there is too much pressure to breastfeed currently? Whether from society, lactation consultants, media, doctors, etc. I believe we don’t have enough proper education on breastfeeding. With good quality education of the risks of not breastfeeding and the benefits to the mother, baby, partnrr and community, as well as having adequate postnatal support, I believe more families would actually choose breastfeeding.
In your opinion, is there anything that can be done to prevent instances where babies or starving or losing too much weight while waiting for milk to come in? The best practice after a normal delivery is keeping babies skin to skin on mom and with free access to nurse on demand. Babies should not be swaddled in isolettes away from their mothers. They should be allowed to sleep with skin to skin contact for the first few days of life. If a baby is not making enough wet and dirty diapers by 48 hours, they need to be evaluated for a tongue tie or other oral motor issues by a therapist in the hospital or a skilled/trained lactation consultant who is trained in oral motor which may be impacting the ability to drain the breast this causing the cycle of not enough milk taken in by baby and the breast not being stimulated by baby to produce more milk.
If not, do you think more breastfeeding mothers should be informed of this scenario before labor? I believe every mother needs to attend a high quality breastfeeding class before birth and breastfeeding support groups after birth. So many mothers don’t get education because they think it’s going to be natural and easy. But we’ve lost the communal/tribal living where we breastfeed with other women and learn about breastfeeding from childhood. There is so much misinformation on social media it perpetuates problems. But I also believe we should be educating mothers about the real impact of epidurals, medications, and induction on breastfeeding so mothers can understand how it will impact breastfeeding.
According to the CDC’s new guidelines, here is how best to care for your pump parts:
Wash your hands before using your pump, and use disinfectant wipes to clean the outside of your pump.
After every use, take apart the pump parts and rinse them under running water. Don’t put them directly in the sink!
Clean your pump parts as soon as possible with hot, soapy water in a wash basin and brush used only for cleaning pump parts, or in the dishwasher.
Rinse in fresh water (don’t put them back in the same basin).
Air dry on a clean dish towel, but don’t rub the parts with the towel as this could spread germs.
Rinse your basin and brush, and leave them to air dry. Clean them as well at least every few days.
If you’re using the dishwasher, place on a hot water and heated drying cycle, or a sanitize cycle. Wash your hands before taking out the parts, and allow them to air dry.
Store items in a clean, protected area only after they’re completely dry.
Breastfeeding reduces mama’s risk of ovarian and breast cancer, heart disease, and osteoporosis. The longer she breastfeeds, the higher the benefit. In fact, a woman who breastfeeds for 8 years has nearly a 0% risk of breast cancer.
Not only that, but breastfeeding a baby girl actually reduces her lifetime risk of breast cancer by 25%.
Ugh. Remember my last post about my horrible eye allergy? The doctor put me on steroid eye drops for a week. I looked up the medication the Hale’s book of medications and breastfeeding. Little had been studied in the drug and lactation, but the risk of it passing into my milk was in the safe zone. I never take a risk with eyes, so I diligently took the drops the prescribed 3x per day. But oooooooooh how it impacted my milk supply!!! If you’ve followed my blog, I was doing great Pumping. And average of 12-19 ounces during an 8 hour shift. With these eye drops on board, my supply dropped to barely 1-3 ounces per pump session for a total of 8 ounces of less per day. I was freaking out to say the least.
Two pump sessions worth in the middle of my eye drop treatment. 😑 Only four ounces total.
I added in two extra pump sessions, one before work and one before bed, to give us a little extra umph and getting us to around 12 ounces for while I was gone at work. Herbs, teas, and cookies were not going to do much if anything because this was being caused by a medication messing at a hormonal level. Pumping was my only hope to get through that week. Fortunately my daughter is on solids and is a champion eater. We just made sure to give her extra foods at meal times and she was waking at night more frequently to nurse. Normally I try not to nurse her at night, but this was an important exception. I was also fortunate to have a four day weekend and I just let her nurse on demand.
This is an entire days worth of pumping. Less than eight ounces for the day.
Two days after the drops were done, my supply came back. The take away is this: if you’re on medications that are altering your supply or if you suddenly notice a change in milk supply and are trying to figure out what changed while trying to breastfeed, don’t give up. Keep pumping and add extra pumps if you need to. If your baby is under six months or not on solid foods, you may need to supplement or nurse more frequently during the night until your supply increases or returns to normal.
First pump of the day today and pumping is back to my normal volume!!!
Fenugreek is one of the most commonly used galactogogues (supplements taken that are known to increase milk production). Fenugreek seeds (per 100 g) are rich sources of protein (46% of DV), dietary fibre (98% DV), B vitamins, iron (186% DV) and several other dietary minerals. The flavorful herb may be found in many Indian, Persian, Turkish, and Egyptian dishes. It is often the key ingredient in mother’s milk teas and lactation bars. Most mothers typically notice an increase in production 24-72 hours after starting the herb, but it can take two weeks for others to see a change. Some mothers do not see a change in milk production when taking fenugreek. Dosages of less than 3500 mg per DAY have been reported to produce no effect in many women. Interestingly enough, it’s been said if you want to know if you’re taking the correct dosage, you’re supposed to slowly increase the amount of fenugreek until your sweat and urine begin to smell like maple syrup. Got pancakes?
However, like any herb or supplement, be aware of what you are injesting. Some people are allergic to fenugreek, specifically people who have peanut allergy and chickpea allergy may have a reaction to fenugreek. Fenugreek seeds can cause diarrhea, dyspepsia, abdominal distention, flatulence, perspiration, and a maple-like smell to urine or breast milk. There is a risk of hypoglycemia particularly in people with diabetes; it may also interfere with the activity of anti-diabetic drugs. It may interfere with the activity and dosing of anticoagulants and antiplatelet drugs. You should not take it if you are pregnant as it may affect uterine contractions and may be unsafe for women with hormone-sensitive cancers. In summary, those with thyroid, blood sugar issues (such as diabetes), peanut allergies and those taking certain blood clotting medications should avoid fenugreek.
References:
Kellymom.com
[Bingel 1991] Bingel AS, Farnsworth NR. Higher plants as potential sources of galactagogues, in Wagner H, Farnsworth NR, eds. Economic and Medicinal Plant Research, Volume 6, Academic Press Ltd, New York, 1994: 1-54. [Brinker 1998] Brinker F. Herb Contradictions and Drug Interactions. Sandy, OR: Eclectic Medical Publications, 1998, 70–1. [Dugue 1993] Dugue P, Bel J, Figueredo M. Fenugreek causing a new type of occupational asthma. Presse Med 1993 May 29;22(19):922. [Hale 2002] Hale T. Medications and Mothers’ Milk, 10th Edition. Pharmasoft Medical Publishing, 2002, p.277-279. [Heller] Heller L. Fenugreek: A Noteworthy Hypoglycemic [Huggins] Huggins KE. Fenugreek: One Remedy for Low Milk Production. [Korman 2001] Korman SH, Cohen E, Preminger A. Pseudo-maple syrup urine disease due to maternal prenatal ingestion of fenugreek. J Paediatr Child Health 2001 Aug;37(4):403-4. [McGuffin 1997] McGuffin M., Hobbs C, Upton R, Goldberg A. American Herbal Product Association’s Botanical Safety Handbook. Boca Raton: CRC Press, 1997. [Ody 1999] Ody P. Herbs to Avoid During Pregnancy from Herbs for a Healthy Pregnancy. Los Angeles, Calif: Keats; 1999. [Ohnuma 1998] Ohnuma N, Yamaguchi E, Kawakami Y. Anaphylaxis to curry powder. Allergy 1998 Apr;53(4):452-4. [Patil 1997] Patil SP, Niphadkar PV, Bapat MM. Allergy to fenugreek (Trigonella foenum graecum). Ann Allergy Asthma Immunol 1997 Mar;78(3):297-300. [Reeder 2011] Reeder C, Legrand A, O’Conner-Von S. The Effect of Fenugreek on Milk Production and Prolactin Levels in Mothers of Premature Infants. J Human Lactation 2011;27(1):74. Abstract only. [Rice] Rice LA. Fenugreek, in Herbal Supplements in Pregnancy [Swafford 2000] Swafford S, Berens B. Effect of fenugreek on breast milk production. ABM News and Views 2000;6(3): Annual meeting abstracts Sept 11-13, 2000
There two important hormones for breast milk production: oxytocin, which is your cuddle hormone, and prolactin, which is your milk maker. During suckling, milk ejection, or “let down”, occurs when oxytocin released into the circulation reaches the mammary glands. Maternal oxytocin is not only released into the circulation by suckling and skin-to-skin contact, but may be released when the mother sees and hears her newborn or simply thinks of him or her. Oxytocin release can even be conditioned to other stimuli, meaning your milk ejection reflex may occur even in the absence of suckling (Tancin, Kraetzl, Schams, & Bruckmaier, 2001). If you’re a Pumping mom this is important to grasp. Try building a routine with your baby during breastfeeding that you can carry over into pumping. Maybe it’s a song you listen to, a smell like lavender or vanilla, or holding a particular blanket. By bringing this into the pump room you can help stimulate oxytocin to help with let down.
