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.
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.
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.
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.
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.
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.
Breast milk for COVID+ mothers contains protective antibodies and no live virus.
There are multiple studies being conducted on breastfeeding mothers who are COVID+. What happens to their milk? A recent multi-institutional research team led by University of Idaho found that breastfeeding women who have COVID-19 transfer milk-borne antibodies to their babies without passing along the virus.
It was a small study where researchers analyzed 37 milk samples submitted by 18 women diagnosed with COVID-19.
🦠None of the milk samples were found to contain the virus
🦠2/3 of the samples did contain two antibodies specific to the virus.
🦠The results indicate that it is safe for moms to continue to breastfeed during a COVID-19 infection with proper precautions.
If you’re actively sick with COVID and still breastfeeding:
🧼 Wash your hands before feeding your baby or pumping
😷 Wear a mask while feeding to prevent coughing directly on your baby
💧 Drink plenty of water
😴 Rest and sleep to let your body heal
💊 Taking Vitamin C, D and zinc have been found to be very beneficial
While your young baby is supposed to gain on average an ounce a day (30gm), weight gain slows as baby ages. From 4-6 months babies should only gain 3-4 ounces per week (90-120gm) and from 6-12 months babies should only gain 1-2 ounces per week (30-60gm). If you have been tracking baby’s weight gain and see the scale slowing down, don’t be alarmed if your baby is older. Continue to watch for lots of wet diapers and consistent pooping. Trust your baby and trust your body.
Some times we can sabotage our own milk supply from little things that we don’t understand will make a difference. Here are the top ways to accidentally drop your milk supply:
😳Putting baby on a feeding schedule in the first 3-4 months
😳Watching the clock instead of feeding baby on demand
😳Sleep training in the first 3-4 months after birth
😳Waiting for your breasts/chest to feel full to pump or feed
😳Not pumping when baby is getting a bottle
😳Letting partner feed a bottle in the middle of the night to get more sleep (and not getting up to pump)
😳”Topping off baby” after feeding, especially during the witching hour phase. (I’m not talking about when supplementing is necessary or if you’re on a triple feeding plan because of true low supply or baby weight gain. Supplementing after breastfeeding can be needed, but you would also be pumping at that time)
😳 Not pumping enough when returning to work
😳Using the wrong size pump flanges
😳Using a poor quality pump (insurance companies have to provide you with one, but that doesn’t mean they’ll give you one of quality)
😳Going back on hormonal birth control at your 6 week postpartum checkup
😳Taking nasal decongestants or allergy medications
While these seem like normal recommendations from many parent groups or even your health care providers, these subtle things can sabotage milk supply. Your body works on a demand and supply basis. The more you empty or demand from the breast/chest, the more milk it will make. Want to increase supply? Increase the number of milk removals, give young infants free access to feed on demand, and watch out for medications, hormones, of pumping traps that can sabotage your success.
Were you told by your pediatrician to give your baby vitamin D drops? Vitamin D is absolutely critical strong bones, because it helps the body use calcium from the diet. Traditionally, vitamin D deficiency has been associated with rickets, a disease where the bone tissue doesn’t mineralize properly, leading to soft bones and skeletal deformities. Recent research also tells us that vitamin D is key in maintaining our immune systems for regulating both infection and inflammatory pathways. If you shun the sun, have a milk allergy, or follow a strict vegan diet, you may be at risk for vitamin D deficiency. Known as the sunshine vitamin, vitamin D is produced by the body in response to skin being exposed to sunlight. It is also occurs naturally in a few foods like certain fish, fish liver oils, egg yolks, and fortified dairy and grain products.
Our bodies are designed to make very large amounts of vitamin D through exposure to the sun (10,000—20,000 IU in 24 hours, after 15—20 minutes of summer-sun exposure in a bathing suit/45—60 minutes of exposure for those with darker skin tones). However, in an effort to decrease our risk of skin cancer from over exposure to the sun, we’ve limited our ability to keep our vitamin D status at a normal level from absorbing it directly from the best source. That said, those living where clouds often cover the sky or in cities with polluted air quality will have a hard time getting sun exposure for natural vitamin D. People with darker skin tones are more likely to have low levels of vitamin D, as well, due to the increased pigment in their skin. They require nearly four times the length of sun exposure in order to penetrate the skin to manufacture vitamin D.
Vitamin D is essential for babies. Your pediatrician cannot tell you to put your baby in the sun, even though that is the best source of vitamin D, because of the risks of skin cancer. So they should have advised you to give your baby 400 IU of vitamin D each day, usually given by drops in the mouth.
All formulas sold in the United States have at least 400 IU/L of vitamin D; so if your baby is drinking 32 ounces of formula, vitamin D supplementation is not needed.
But what about from breast milk? Human milk is a very poor source of vitamin D, usually containing less than 50 IU per quart. This is why the AAP recommends all breastfed infants be supplemented. This does not mean there is anything wrong with the milk, but an issue in the recommended amount of vitamin D the lactating parent should be taking. This goes back to the sunlight recommendation. If you were getting 15-45 minutes of sunlight (depending on how dark your skin tone is) 3-4 times per week, your body would have plenty of natural vitamin D to pass through your milk to your baby. Many who live in the US either don’t live in a location where that’s possible year round (hi, Chicago in January) or maybe can’t get out in the sun because of needing to work. The Academy of Breastfeeding Medicine (a global organisation) recommends that “The breastfeeding infant should receive vitamin D supplementation for a year, beginning shortly after birth in doses of 10–20 lg/day (400–800 IU/day) (LOE IB). This supplement should be cholecalciferol, vitamin D3, because of superior absorption unless a vegetable source such as ergocaliferol vitamin D2, is desired. … Vitamin D also may be delivered adequately through human milk.” Research has shown that as long as you as the lactating parent is taking 6,400 IU of vitamin D daily, there is no need to supplement the baby as your milk will have adequate amounts.
