The science vs the art of breastfeeding

SCIENCE AND ART

Breastfeeding is the perfect blend of science and art. There are basic principles that apply, but within those principles is a lot of variation

🔬Science says you should switch which breast you start with at each feeding to keep milk supply balanced

🎨Art says this mom always starts left to try to increase supply on the slacker boob while that mom only feeds one breast per feeding. This mom needs to block feed and that mom offers whatever breast passes the boob shake fullness test

🔬Science says babies should poop at least once a day

🎨Art says some babies poop every time they sit in the car seat and others in the bathtub🤷🏽‍♀️ Some babies poop after every feeding and others have just one a day (or every other day)

🔬Science says eat whatever you want

🎨Art says one can eat dairy without a problem for baby and for another it causes a rash and digestive upset in baby

🔬Science says having baby in a good position will get you a deep latch.

🎨Art says you over here love koala hold a rolled up wash cloth supporting your breast to help reduce reflux. While you over there do better in cross cradle sitting up.

🔬Science says as baby ages they can sleep in longer stretches at night

🎨Art says many babies still wake up 1-3 times a night to nurse until 18 months and need help from an adult to transition back to sleep

🔬By understanding the science behind breastfeeding, we can understand typical patterns of behavior which helps guide us when things aren’t going well.

🎨By appreciating the art of breastfeeding, we can celebrate the unique differences of every feeding baby within its own family dynamic.

🔬If you’re struggling with the science of breastfeeding, find help.

🎨If breastfeeding is going well, appreciate the art of your own masterpiece that you’re creating with your little one.

My baby won’t breastfeed I think there’s a tongue tie

As an SLP/IBCLC, I look at three things when doing an assessment on infants: what does the tongue look like, what can the tongue do, what symptoms is it causing. The tongue needs full range of motion (in and out, side to side, and up and down ) for feeding, dental hygiene and to some extent speech. You can have a frenulum can still have good range of motion. A frenulum is considered tied when the tongue can’t move in all directions and it’s causing symptoms because it’s not functioning correctly.

Symptoms to watch out for are:

👅Can not grasp and hold a nipple for breast or bottle feeding

👅Pops on and off the breast/unable to latch or maintain the latch

👅Leaks milk from breast or bottle

👅Fatigues easily from tension on the tongue and jaw/“sleepy” at the breast

👅Wants to feed all the time and never seems satisfied

👅Causes nipple pain and damage when latched

👅Pinches the nipple when feeding causing recurrent plugged ducts and mastitis

👅Doesn’t empty the breast well causing low milk supply

👅Tongue constantly in a “stimulation” mode instead of efficient sucking at the breast, causing an over supply of milk with fast let down

👅Cannot create the vacuum needed to draw breast milk and makes a clicking or loss of suction sound at the breast

👅Poor weight gain

👅Chokes and gags during feeding

👅Fussy at the breast

👅Swallows air while feeding causing reflux, gassiness or colic

When range of motion is restricted, or is causing symptoms, I will refer to a pediatric dentist who also looks at how the frenulum is impacting structure: is it pulling on the structures of the floor of the mouth and the jaw? Is it putting tension on the bone? In those cases, when function is restricted and it is currently causing symptoms, a revision is warranted. I never recommend revision to avoid symptoms down the road. It’s not ethical.

Nursing aversions and breastfeeding strikes

NURSING AVERSION

My baby won’t take the breast and is completely refusing to eat. What do I do? I see cases like these occasionally and I feel like they’re some of my most challenging (and most rewarding) cases. If your infant under 6 months is displaying aversion to feeding, we need to figure out why. Aversion to feeding means screaming or crying when even offered the breast, taking very little from the breast, 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. A nursing strike that isn’t managed well can turn into a feeding aversion, though. The behaviors seen in baby are much more extreme for a true aversion. Here is my list of the most common culprits to a true breast aversion in order of most common cause in my experience.

👅Tongue tie/oral motor: Is there a visible tongue or lip tie? One of my biggest red flags for tongue tie is reflux and shutting down during breastfeeding (sleepy baby 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 as they’re compensating from a full milk supply. The aversion comes around 3-4 months when moms supply regulates and is dictated by the efficiency and responsibility of baby removing milk from the breast. If there is no tie, what’s the baby’s sucking pattern like? Do they have an immature or disorganized suck? How is their latch? Are they possibly taking in too much air with poor latch causing discomfort? Would a different bottle nipple shape or pacing be more appropriate? Do they struggle at the breast but take a bottle occasionally? Address the ties and do oral motor exercises to strengthen and coordinate the system and the refusal goes away.

🥛Intolerances/Allergy: This can look similar to reflux, but there is often a component of bowel issues involved as well (constipation with uncomfortable bowel movements, diarrhea, or mucousy/foamy poops). Look for patterns with formula changes- sometimes parents will say one formula works better than another, and if we look at the formula ingredients we might understand which ingredients baby is sensitive to. Babies who’s digestive tracts are uncomfortable don’t want to eat. They learn really quickly to associate feeding with pain, so they shut down on feeding. Finding the allergens clears the gut and makes feeding pleasant again.

🤮Reflux: Easiest culprit to blame and mask with medication. To be honest, putting baby on reflux meds rarely makes a difference. The medication may mask the pain but won’t actually take the reflux away. Don’t get me wrong, for some babies it can make a big difference, but let’s get to the root of the reflux. And medications should always be a last resort. Is the baby spitting up (doesn’t always happen with reflux)? Is there pain associated with the spit up? Is it projectile and frequent? Does the refusal stop once the bottle is removed or are there signs of discomfort even after the bottle is removed? Wanting small, frequent feedings is my classic tell tale of reflux. Continually swallowing helps keep acid in the stomach and reduces the pain. True reflux is usually caused by food allergy/intolerance, gut issues, or tongue tie. Address the issue, resolve the reflux.

🥵Aspiration: Milk going into the lungs instead of to the stomach. Is the baby stressed during feeding? Do their nostrils flare and their body get stiff or arch? Do the cough and choke throughout the feeding and not just during let down? Do they have noising breathing or feeding? Do you need to be super careful with position change/flow rate changes? Do they have a respiratory history (not just pneumonia- does the baby take long periods to get over any illness)? Further assessment by a speech pathologist is always needed.

🤯Behavioral: I’m not sure if “behavioral” is the correct word, but it’s the best way to describe it. The number one concern of parents is feeding the baby. When feeding isn’t going well, it causes extreme stress, which can cause us as 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 (or not being able to figure out the why in the first place). Occasionally the reason for the refusal is not longer there, but it was so stressful in the moment, the panic that it could happen again sets in and perpetuates the problem unnecessarily. 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. Are you just trying to push past baby’s stress signs due to your own stress with trying to get baby fed? Are you just trying a bunch of different things to see what works? Are you trying to feed based off of old information? You are just trying to do your best and are scared for baby, but sometimes the compensatory things we do can cause more problems or cause it to persist. Having an outside observer come in to help see what’s going on can help bring everyone back to baseline.

When trying to figure out which of these culprits is the cause of the aversion, know that you don’t have to figure it out alone. Finding a trained lactation consultant (🙋🏽‍♀️) can help ask the right questions to get to the root of the issue and get feeding back on track.

Does breast shape impact making milk?

We come in all different shapes and sizes, and so do our breasts/chests. They can be large, petite, round, tubular, wide, narrow, symmetrical, uneven, teardrop shaped, or droopy. All of these types of breasts/chest are normal.

The size of your breasts/chest is based upon the amount of fatty tissue in it. Those with smaller breasts have less fatty tissue, and those with larger breasts have more fatty tissue. The fatty tissue doesn’t make breast milk. Glandular tissue inside the fatty tissue produces the breast milk.

Unlike fat, the amount of milk-making tissue in your breasts is not necessarily related to the size of your breasts. People with all different breast sizes are fully capable of producing a healthy supply of breast milk for their babies.

Smaller breasts does not necessarily mean smaller milk supply. As long as the small size is not related to hypoplastic breasts (not enough glandular tissue), there shouldn’t be an issue. While you may have to breastfeed more often due to the amount of breast milk that your breasts can hold, you can still successfully produce enough milk.

Breastfeeding with large breasts has its own unique challenges, usually related to position and how to hold or support the breast. Side lying or rolling a towel to put underneath the breast to lift it can be very helpful. Some worry that their breasts will block baby’s nose. Pulling baby in the opposite direction of the breast and compressing the breast from the back can help pop baby’s nose up off the breast. If your baby’s nose gets blocked while nursing, they will open their mouth and let go of the breast so they can breathe.

If you were told your breasts were too big or too small to breastfeed, I am so sorry. Your body is perfect just the way it is.

If you’re concerned that you’re not producing enough milk, pay attention to your baby’s wet diapers and bowel movements. Generally, small infrequent bowel movements or less than six wet diapers a day, are cause for concern. Contact a lactation consultant (🙋🏽‍♀️)right away.

Why does my breast milk supply drop during my period?

Did you know that many of us will notice a supply drop right before our period is going to start and lasts through the period? This is caused by hormone shifts in your body. As supply dips, the milk flow slows. Research shows that the composition of breast milk changes around ovulation (mid-cycle). The levels of sodium and chloride in the milk go up while lactose (milk sugar) and potassium go down. So, the breast milk becomes saltier and less sweet during this time. Some babies become frustrated with this change. They may grab the nipple with their mouth and shake their head back and forth. Pop on and off the breast. Knead or beat the breast with their hands or become extra fussy at the breast. They may even cluster feed and act as if they’re still hungry. They’re trying all the strategies to get your milk to flow how they prefer.

Also around the time of ovulation and just before the start of your period, estrogen and progesterone levels change which can affect your breasts and your breast milk. When estrogen and progesterone levels go up, it can make your breasts feel full and tender.

Higher estrogen levels can also interfere with milk production. Studies also show that calcium levels in the blood go down after ovulation. The lower level of calcium may also contribute to the drop in the milk supply. Lower levels of calcium may also cause your nipples to feel sore, making breastfeeding during your period uncomfortable or sometimes painful.

This is a temporary dip but can be surprising the first time it happens. Remember: this dip can happen once or twice before you actually have a period as your hormones are shifting back into baby making mode. If your baby is older than 6 months and eating lots of solids, you may not notice a difference. The strongest behaviors are seen under 6 months when babies need an exclusive milk diet. You may also notice the dip if you’re a pumper.

Having your period start again may not have any effect on your baby or your milk supply. Some babies continue to breastfeed well. Others will not like the taste of the breast milk or the drop in the amount of breast milk that can happen when your period returns. Your baby may:

  • Become fussier than normal
  • Want to breastfeed more due to the lower milk supply
  • Breastfeed less because there is less breast milk and it tastes different
  • Nursing strike

What can you do about it? Knowing it can happen is the first step. Stay well hydrated and eat quality nutrition. Many find adding in a calcium/magnesium supplement (1000mg of calcium/500mg magnesium per day split into 3-4 “doses”) can help combat the drop. Others find adding in lactation specific herbs or supportive foods help. Iron rich foods like dark leafy greens and red meat and milk making foods like oatmeal, almonds and fennel can really help. Keep offering the breast or pumping frequently. It will get better and your supply will come back up as soon as your hormones shift again after your period. It usually only lasts a few days.

Word to the wise: You can release an egg from your ovary (ovulate) before your period returns. If you’re involved in an intimate relationship, and you’re not using birth control, you can get pregnant again without ever getting your first period even while you’re breastfeeding. If you notice a very drastic drop in milk supply, consider taking a pregnancy test.

Maternal vaccines and breastfeeding

Did you know babies routinely get antibodies to anything you’ve been vaccinate against? Babies get temporary disease protection from you in this way. When you are vaccinated, your body has an immune response that makes antibodies to what you were vaccinated against. Antibodies are then secreted in breast milk to your baby. The type and quantity of these antibodies, and whether they provide any protection for baby after they are swallowed, are dependent on the vaccine received and maternal factors that influence immune system function such as genes, age and health.

Antibodies in breast milk have not been shown to reduce baby’s response to their own immunizations. However, some studies suggest that breast milk may improve baby’s immune response to some of the vaccines they receive.

If you do decide to be vaccinated while breastfeeding, there is no need to pump and dump your milk. Or to stop breastfeeding for any amount of time. When considering the vaccine, or any medication, most want to know whether a dangerous amount of a substance will be filtered into our milk and cause harm to our baby. For most drugs, so little gets to the baby that there’s really very little theoretical risk. Even if a drug or vaccine does end up in breastmilk, anything that goes through breastmilk also then has to go through baby’s gut before reaching baby’s bloodstream. The mRNA molecules in the Pfizer or Moderna vaccines, if they made it into your milk, would have to survive baby’s stomach acid first.

While breastfeeding, it is highly unlikely that an intact lipid from the vaccine would enter your blood stream and be passed directly into your milk. If it does, it is even less likely that either the intact nanoparticle or mRNA could be transferred into your milk. In the unlikely event that mRNA is present in your milk, it would first go through baby’s digestive system and would be unlikely to have any biological effects. The vaccine is supposed to trigger an immune response in your body. It helps your body recognize the virus when you’re exposed and fights the virus early, reducing the severity and length of illness. Once your immune system recognizes the SARS-CoV-2, the virus that causes Covid-19, antibodies are made to protect you and those antibodies may pass into the breastmilk. Researchers have already found Covid antibodies in the breastmilk of previously infected women, though they don’t know yet how much protection these antibodies give babies.

Choosing to be vaccinated is a personal risk/benefit decision to be made between you and your health care providers. If you do chose to be vaccinated with the COVID vaccines, there is no need to pump and dump for concerns of your milk harming your baby.

The Second Night

Second Night Syndrome : What absolutely every parent should be warned about in pregnancy.

Second night syndrome. I hate the word syndrome. It implies something is wrong. For nine months your baby has been in your belly. Heard your voice. Felt your body move. Listened to the rush of your blood flow past and heard the gurgle of food digesting. Their existence controlled by the cycles of your body. Then the intensity of labor and delivery propels them into a new world that sounds, smells, and moves differently. The sheer exertion of being born often makes babies as tired as their mothers. It is typical for babies to have a deep recovery sleep about 2 hours after birth (after their 1st breastfeed).

On the second night, however, most babies will want to frequently nurse. This helps with two transitions: meconium to soft, seedy yellow poops and colostrum to mature milk. This cluster feeding catches many parents by surprise and leaves them wondering if baby is starving. Unless baby is not latched well or efficiently feeding, this is normal and the cluster feeding will help transition your milk.

Many babies, though, don’t want to be put down during this process. Each time you put them on the breast they nurses for a little bit, go back to sleep and then cry when placed in the crib. A lot of moms are convinced it is because their milk isn’t “in” yet, and baby is starving. It isn’t that, baby’s awareness that the most comforting place is at the breast. It’s the closest to “home”. This is pretty universal among babies. When baby drifts off to sleep at the breast after a good feed, break the suction and take your nipple gently out of their mouth.

This is also protective of SIDS. You’re exhausted from labor and delivery and just want to sleep. But night time is when newborns are most vulnerable to respiratory complications and SIDS. By waking you frequently at night, you are waking frequently to check on the well being of your baby when they’re at their greatest risk of infant death. Waking regularly at night for the first few months to feed also helps babies from getting into too deep of a sleep state which can cause them to stop breathing. Instead of seeing the loss of sleep as a negative for you, consider the positive reason it has for baby.

Don’t try to burp baby, just snuggle baby until they fall into a deep sleep where they won’t be disturbed by being moved. Babies go into a light sleep state (REM) first, and then cycle in and out of REM and deep sleep about every ½ hour or so. If they start to root and act as though they want to go back to breast, that’s fine… this is their way of comforting. During deep sleep, baby’s breathing is very quiet and regular, and there is no movement beneath the eyelids. That is the time to put them down.

Second night syndrome. As described above, when all is going well it is normal for baby’s to cluster feed on the second night to help milk transition and poop out meconium. Some babies do not efficiently feed, though, and intervention may be necessary.

🩺Medical interventions and pain relief during labor and delivery, maternal health complications like PCOS, uncontrolled diabetes or hypothyroidism, or large blood loss during delivery may delay the transition of your milk.

🧸If your baby not latched well, has a tongue tie, or hasn’t figured out how to coordinate sucking to actually transfer milk from the breast, intervention may also be necessary.

🖐🏽The first line of defense is hand expressing your milk frequently. Hands are better at expressing colostrum than a pump, although a pump is a great way to stimulate milk to be made.

🥄Dripping your milk into baby’s mouth from a spoon or small syringe can help jump start the feeding process.

❓If you have any doubt about either your milk supply or your baby’s ability to breastfeed well, reach out to a qualified IBCLC ASAP to get to the root issue and get you back on track.

♥️There is no shame in supplementing your baby if needed during this time of learning. Remember, you can always use your milk first by using your hands or a pump if baby hasn’t figured it out yet.

Do I need to night wean because of cavities?

Were you told by your dentist to night wean your breastfed baby for concerns of it causing cavities? Extensive research has proven that there is no link between breastfeeding (nighttime or otherwise) and cavities. Breastfed babies can get cavities, though, so good dental hygiene is still needed.

Over three dozen studies have proven that cavities found in toddlers and young children (also called caries) were not caused by nursing – breastmilk is not cariogenic – but by an infectious disease classified as Early Childhood Caries (ECC). Furthermore, according to the National Institute of Dental and Craniofacial Research (NIDCR), breastfed children are less likely to develop ECC than children who are bottle-fed, and population-based studies do not support a link between prolonged breast­feeding and ECC.

According to La Leche League International (LLLI), “Breast­feeding is typically assumed to be a cause of dental caries because no distinctions are made between the different compositions of human milk and infant formula or cow’s milk, and between the different mechanisms of nursing at the breast [with the nipple at the back of the mouth, not allowing for breastmilk to pool around the teeth] and sucking on a bottle with an artificial teat. We have only to consider the overwhelming majority of breastfed toddlers with healthy teeth to know that there must be other factors involved.”

The Centers for Disease Control (CDC) also stopped using the terms “bottle-mouth” and “nursing caries” in 1994, thereby acknowledging early childhood caries as an infectious disease not caused by breast- or bottle-feeding. Most current studies now focus on the true causes of cavities in children, contributing factors, and prevention or cures.

Early Childhood Caries (ECC) appears on teeth as white spots, plaque deposits, or brown decay and can lead to teeth chipping or breaking in children under five. They are formed by bacteria sitting on the teeth which feed off of the sugars found in formula, juice, milk, and food. These and other factors, such as the frequency of feedings, oral hygiene, medications, other medical and dental conditions, determine the risk of your child developing a cavity. Once the pattern of decay begins, though, it can be extensive.

The CDC and the dental and medical communities consider ECC to be the most prevalent infectious disease of American children (5-8 times more common than asthma). Approximately 8.4 percent of all children will develop at least one decayed tooth by age two, and 40.4 percent by age five. Of these cases, 47 percent of children between the ages of two and nine never receive treatment. According to the CDC, “Untreated decay in children can result in chronic pain and early tooth loss … failure to thrive, inability to concentrate at or absence from school, reduced self-esteem, and psychosocial problems.”

While researchers have recognized S. mutans as the primary bacteria responsible for ECC, there are other surprising risk factors which make children more susceptible to cavities than others. Significantly high correlations have been found between ECC and pregnancy complications, traumatic birth, and cesarean sections. Other risk factors on the maternal side which increase the risk of ECC include maternal diabetes, kidney disease, and viral or bacterial infection. Babies born prematurely, with Rh incompatibility, allergies, gastroenteritis, malnutrition, infectious diseases, and chronic diarrhea are also at increased risk of cavities. Diets high in sugar AND/OR salt (such as French fries and chips), iron deficiency, pacifier sucking, and prenatal exposure to lead are also ECC risk factors.

Along with these risk factors, what can cause cavities are nighttime bottles and not brushing teeth before bed once baby has teeth, and especially if they are also eating solid foods. Bottles allow liquids to pool in baby’s mouth and sit on baby’s teeth for long periods of time. Breastmilk doesn’t pool in the same way because milk only flows when baby is actively sucking. When baby is latched appropriately to actually express breastmilk, it enters the baby’s mouth behind the teeth. If the baby is actively sucking then he is also swallowing, so breast milk doesn’t sit in baby’s mouth like it can with bottles. Sugars from table foods can sit on the teeth and bacteria in saliva uses these sugars to produce acid, which in turn causes tooth decay. Actively brushing baby’s teeth twice a day helps reduce these sugars from sitting on the teeth.

So no need to night wean for cavities… but if you need the sleep I completely understand.

When can you take your child to the dentist for the first time? As soon as they have teeth! This is Peachy’s first cleaning at 19 months. We went a little later than when I took her sister for the first time, but #COVID. I highly recommend finding a pediatric dentist who have staff that are highly trained with working on tiny tots. It will make the experience so much better. Having movies on the ceiling didn’t hurt 😉

Vernix, delayed bathing, and breastfeeding

My little Peach right after birth

The vernix caseosa is a greasy, cheese-like coating that covers baby’s skin in the womb to protect their skin from getting pickled by amniotic fluid prior to birth. According to present knowledge, vernix production is unique to humans. At birth, vernix may cover the entire skin surface or only be found in body folds. Its color may actually help indicate intra-uterine problems or disease.

😳In utero: When swallowed by baby in utero, vernix helps:

• Develop the gut

• Prevents loss of electrolytes and fluids

• Seals the skin to prevent the amniotic fluid from turning baby into a raisin

• Acts as a microbial barrier from pathogens

• Protects skin growing underneath it

😳In birth: The oily texture may naturally lubricate the birth canal to reduce friction as baby makes their exit. It can also help with mother’s perineal healing!

😳 In postpartum:

• Vernix protects baby’s skin from drying out

• Reduced risk of bacterial infections

• Help baby retain heat

😳 In breastfeeding: The scent of vernix might be involved in triggering neural connections in babies’ brain needed for breastfeeding. The immune proteins found in vernix and amniotic fluid are similar to those found in breastmilk. Swallowing vernix and amniotic fluid in utero help coat baby’s lungs and digestive tract, preparing the digestive tract for the similar peptides found in breastmilk. The smell may also help baby find the breast!

The majority of the vernix is absorbed within the first day, so so it’s recommended to wait until after the first 24 hours to bathe baby. Vernix doesn’t fully absorb until day 5 or 6, so it’s best to wait until then.

Paced bottle feeding

Paced bottle feeding (meaning you’re setting the pace for how fast/slow baby drinks) helps prevent over feeding baby: it takes 20 minutes for the stomach to tell the brain that it’s full. If a baby takes a bottle too quickly, the mouth can still be “hungry” and wanting to suck when the stomach is actually full. Like going to an all you can eat buffet and eating a lot of food quickly and then realizing half hour later you ate way too much. A baby that happily sucks down too much milk from a bottle can make you think you don’t have enough breast milk even if you make a normal amount. It can also make baby frustrated by the flow of milk from the breast and inadvertently sabotage breastfeeding

These pictures are the same baby in two different positions for paced feeding: semi upright and side lying. Side lying is my favorite position to use as it puts baby in the same position as breastfeeding. Many parents feel baby is more supported in this position. Baby is supported by your leg or breastfeeding pillow.

Tips:

🍼Never feed baby on their back

🍼Keep the bottle parallel with the floor with about half the nipple filled with milk

🍼Use the slowest flow nipple baby will tolerate

🍼Rub the nipple gently on baby’s lips, allow baby to latch at their own pace, don’t force it into their mouth

🍼It should take 15-20 minutes to finish the bottle

🍼Watch the baby and not the bottle, stop when they show signs of being full

🍼Resist the urge to finish the bottle, even if there is only a little left, when baby is showing signs their tummy is full

🍼Take short breaks to burp and give the tummy time to fill naturally

🍼If baby is gulping or chugging, slow down

🍼If baby has taken a good volume of milk (2-4oz) in a short amount of time and is still acting hungry, offer a pacifier for a few minutes to help them digest and give the tummy to to tell the brain it’s full. If they’re still hungry, slowly offer more in 1/2oz increments