I was inspired to write this post due to some recent helping situations.  I decided to compile all this information in one place.  I may add to it later.

In order to have an excellent milk supply, it is important to remove milk from the breasts at least 8-10 times a day. (http://feedthebabyllc.comcare-plan-for-milk-supply/)  When parent and baby are together, it is beneficial to keep baby skin-to-skin and allow free access to the breast.  A baby is usually better at maintaining a milk supply than a pump and the extra nursing stimulates breasts to make more milk.

When a breastfeeding parent is separated from baby, it is important to express milk as frequently as possible, at least every 3 hours from the beginning of one expression to the beginning of the next.  A double electric pump with properly fitting flanges works the best.  Be sure to check the membranes frequently and change them at least every 3 months.  A pump that is older than 1 year may not be as efficient.  See (http://newborns.stanford.edu/Breastfeeding/MaxProduction.html) for learning a technique that increases the amount of milk that can be expressed by 48%!

Read more Maintaining a Robust Milk Supply When Parent and Baby Are Separated ›

In Honor of IBCLC day, March 6^th 2013, I decided to explore the reasons why I chose to become an IBCLC, though there are easier and less costly pathways to providing professional breastfeeding support.

I had already been an active La Leche League volunteer leader for nearly 12 years when I decided that I wanted to extend my services to include professional breastfeeding support.  I knew that I had acquired a lot of the experience and knowledge needed through my volunteer work.  I had dedicated thousands of hours to learning about and supporting breastfeeding.  I had helped several hundred parents overcome breastfeeding difficulties and realize their breastfeeding goals.  I did not believe, however, that this was adequate training to provide professional breastfeeding services. Read more Why I Became an International Board Certified Lactation Consultant ›

Tongue and lip-tie are common causes of nipple pain, uneven breast drainage, slow weight gain and low milk supply. Many physicians do not properly assess for tongue or lip-tie or recognize their impact on the breastfeeding relationship, leaving babies vulnerable to early weaning.

This photograph  shows a very obvious tongue-tie and visible frenulum (the bit of tissue holding down the tongue) but not all restrictions are this obvious. Some restrictive frenulums attach further back on the tongue. Some are even buried under the floor of the mouth, causing the tongue to appear, “short.” The only visible indication may be that the floor of the mouth rises when baby lifts his tongue or the tongue stays flat or doesn’t rise to the palate when baby cries. Sometimes the sides of the tongue will rise but the center of the tongue will stay on the floor of the mouth. Even if a baby can reach his or her tongue past the gums or lips, there may still be a tight frenulum restricting baby’s ability to breastfeed effectively.

Ultrasound studies have shown that the tongue movements used by tongue-tied babies are qualitatively different from those used by by babies who are not tongue-tied. These movements are not as effective at removing milk from the breast and can cause significant pain and nipple damage.  In these studies, tongue-tied babies also did not draw the nipple as deeply into the mouth as babies who were not tongue-tied.

Some babies with tongue and/or lip-tie may manage to nurse well enough to gain weight adequately in the early weeks, but they may not be able to maintain a full milk supply as they grow.  Their restrictions will likely continue to affect the ease of breastfeeding.  Feeds may be long and frequent–10-12 times a day or more.  Often these babies do not nurse for comfort and may have difficulty managing solids when they are older.

Tongue and lip-ties affect more than breastfeeding.  Even if a baby can breastfeed well and without causing pain, restrictive frenulums can affect jaw and dental development, breathing, chewing, swallowing and digestion.  Tongue and/or lip ties are also associated with reflux, which can cause significant pain for baby and may result in the need for medication.

Any of the following symptoms in parent or baby may indicate that tongue-tie is affecting breastfeeding.

Signs in parent:
•nipple pain and/or erosions
•nipple looks pinched, creased, bruised, or abraded after feeds
•white stripe at the end of the nipple
•painful breasts/vasospasm
•low milk supply
•plugged ducts
•mastitis
•recurring thrush
•frustration, disappointment, and discouragement with breastfeeding
•weaning before mom is ready

Signs in baby:
•poor latch and suck
•unusually strong suck due to baby using excess vacuum to remove milk
•clicking sound while nursing (poor suction)
•ineffective milk transfer
•infrequent swallowing after initial let-down
•inadequate weight gain or weight loss
•irritability or colic
•gas and reflux
•fussiness and frequent arching away from the breast
•fatigue within one to two minutes of beginning to nurse
•difficulty establishing suction to maintain a deep grasp on the breast
•breast tissue sliding in and out of baby’s mouth while feeding
•gradual sliding off the breast
•chewing or biting on the nipple
•falling asleep at the breast without taking in a full feed
•coughing, choking, gulping, or squeaking when feeding
•spilling milk during feeds
•jaw quivering after or between feeds

Assessing baby for tongue-tie: (baby may not have every sign)
•Does baby’s tongue rise less than half-way to the palate when crying?
•Do the sides of the tongue lift but not the center?
•Can you see a dip in the tongue in the center of the mouth?
•Does tongue have a heart shaped tip?
•Does baby have a high, narrow or bubble palate?
•Can you see or feel a tight frenulum?

To feel for a restrictive frenulum, you can use the “Murphy Maneuver,” developed by San-Diego pediatrician Dr. James Murphy. Put your little finger at the base of baby’s tongue and draw across the floor of the mouth. If you feel a resistance in the center of baby’s mouth, that is the frenulum. If you cannot get past this frenulum without going around it, then it may be restrictive enough to affect baby’s ability to breastfeed.

The following link shows a method for visualizing a restrictive frenulum that is difficult to see.

http://www.youtube.com/watch?v=5opSbXvL7yQ

Lip-ties often accompany tongue-ties. If you lift your baby’s upper lip and see a frenulum that is tight and if the gums blanch (turn white) when the lip is lifted, your baby may have a lip-tie. The following two articles may help with assessing for lip-ties.

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

What Can You Do?

Cranio Sacral Therapy is a helpful intervention for babies with restrictive frenulums.  CST is a light touch therapy that releases tight muscles and can improve baby’s ability to latch and breastfeed, but CST may need to be repeated frequently order to maintain its effectiveness. There are exercises that might help a baby to compensate for the restrictions and careful attention to latch and positioning, may also help the baby to breastfeed more effectively.  None of these interventions enable the tongue-tied baby to have full mobility of the tongue and they are most effective when used along with release of restrictive frenulums, in order to normalize function.  This procedure is performed with surgical scissors or laser and is called a frenotomy.

Many babies with restrictive frenulums cannot nurse effectively unless both tongue and lip-ties are revised by frenotomy.  With an experienced provider, revision is quick and discomfort is minimal.  The discomfort from a frenotomy varies from unnoticeable (some infants sleep through the procedure) to about the same amount of pain as a from a vaccination.  The baby can nurse immediately afterward which also relieves pain.

If breastfeeding hurts the parent or if baby struggles to get enough milk, then the breastfeeding relationship is at risk.  The risks of not breastfeeding outweigh the temporary discomfort of revision.  If you are considering a tongue and/or lip-tie revision, it is important to find a provider who is very experienced in revising restrictive frenulums in infants and who is very familiar with how these restrictive frenulums affect breastfeeding. Experienced providers will know how to revise completely and without the need for general anesthesia.

The following is a link to a video of laser tongue-tie revision in a 14 year old. The doctor has made this available for anyone to view. The mom wanted to have this procedure done because her daughter had jaw tension, clenching and tooth grinding. She also breastfed poorly as an infant.
http://www.youtube.com/watch?v=OmyksitDV70&feature=player_embedded

For more information, visit the following links:

lactationkotlowTTnursingbookaugfc2011-1

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

http://kiddsteeth.com/articles.html

www.lunalactation.com/KnoxTT.pdf

American Academy of Pediatrics–Tongue-Tie

http://www.brianpalmerdds.com/

http://www.ncbi.nlm.nih.gov/pubmed/12415069

http://www.llli.org/llleaderweb/lv/lvaprmay02p27.html

http://lowmilksupply.org/tonguetie.shtml

http://breastfeeding.blog.motherwear.com/2011/01/guest-post-shannon-on-posterior-tongue-tie.html

kiddsteeth.com/articles/aerophagia_2011.pdf

http://www.tonguetie.net/

© 2012 Laura Spitzfaden, IBCLC (www.feedthebabyllc.com) laura@feedthebabyllc.com

I think this is a very helpful technique for moms who are having difficulty achieving a comfortable latch due to mom’s or baby’s anatomy.

The following is posted with permission from http://www.drmomma.org/

Breastfeeding Latch Trick

By Danelle Frisbie © 2010

Read more Nipple Latch Trick ›

I was inspired to write about milk-sharing when I read this article by Amber McCann, IBCLC.

http://www.ambermccann.com/blog/milksharing/

Like Amber, I am an International Board Certified Lactation Consultant.  I am also a La Leche League Leader.  La Leche League’s position on milk-sharing discourages leaders from providing moms with information about informal milk-sharing unless the mother specifically requests such information.  [Update] La Leche League International offers guidelines on human milk sharing. If mothers ask a LLL Leader how to obtain human milk supplements for their babies, they must be directed to milk banks, even though the cost of purchasing human milk from a milk bank is prohibitive.  In most cases, there is not enough milk available for the ill or preterm babies who need it, let alone any excess available for purchase for healthy babies.  This is simply not a viable option for most families. Read more Milk Sharing ›

I would like to promote these amazing videos created by the Norwegian, mother-to-mother breastfeeding support organization, Ammehjelpen.  Each video is available in Norwegian and in English.  After clicking on a video, scroll down for the English version.

Breastfeeding Videos

Learn to hand-express colostrum. This milk is already in your breast and will be your baby’s first food.  If your baby has any difficulty latching in the first few days, you can hand express this colostrum and feed the baby by spoon. Parents with gestational diabetes may even consider expressing and freezing some colostrum while pregnant, in case supplementation is indicated after birth.  This article written by By Deanna M. Soper, PhD and posted at the Breastfeeding USA website outlines the benefits and concerns regarding milk expression before birth.

***Edited 2017*** A new study in the Lancet suggests that prenatal colostrum expression in low risk pregnancy is safe.

Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial Forster, Della A et al. The Lancet , Volume 389 , Issue 10085 , 2204 – 2213 June 2017

Do not use this frozen colostrum as a replacement for feeding at the breast!  It is important to future milk supply that colostrum is removed in the first few days after birth, by breastfeeding or by hand expression.

http://www.bfmedneo.com/BreastMassageVideo.aspx (From Breastfeeding Medicine of Northeast Ohio)

http://ammehjelpen.no/handmelking?id=907  (video created by the Norwegian mother to mother breastfeeding support organization, Ammehjelpen–scroll down for English video)

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Birth

Immediate skin-to-skin contact is best for parent and baby and their breastfeeding relationship.  Remain in skin-to-skin contact, as much as possible, until your baby is breastfeeding easily.  Skin-to-skin contact promotes stable temperature, heart rate, breathing and blood sugar.  This allows your baby to be in the most receptive state for learning to breastfeed.  Babies in skin-to-skin contact are more likely to latch and breastfeed well, right from the start.

Immediate skin-to-skin contact after birth also helps to properly colonize baby with parent’s bacteria.  Babies become colonized with the bacteria they contact in the birth canal and on the parent’s skin.  Babies who are born by cesarean have not come into contact with the bacteria in the birth canal and are especially vulnerable to being colonized with hospital bacteria.  Colonizing baby with parent’s bacteria, may also help prevent a hospital acquired bacterial infection of the breast or nipple.

Do not allow anyone to put anything into baby’s mouth unless medically necessary. Suctioning should be avoided if possible.  Ideally, baby’s first oral experience is to latch and breastfeed.

Delay routine procedures until baby has latched and breastfed or for at least the first hour. If your baby is healthy, there is no medical reason to separate parent and baby for routine procedures.  Baby’s temperature stabilizes best on parent’s chest and breastfeeding is facilitated by protecting this critical first hour.  Even after cesarean birth, baby can be immediately placed on parent’s chest.

Day 1

Stay in skin-to-skin contact, do not swaddle baby.  Swaddled babies do not stay as warm as babies in skin-to-skin contact and they do not breastfeed as well or as frequently.  Babies use their hands to help them find the breast and to stimulate the breast and nipple to release milk.  Swaddling deprives babies of the use of their hands and inhibits many other inborn feeding reflexes.

Use a laid-back breastfeeding position. http://www.biologicalnurturing.com/  This position involves lying back comfortably, well supported by pillows, while allowing baby to lie against your body, with his head just above and between your breasts.  Gravity and contact with your body stimulates baby’s inborn feeding reflexes and allows him to find his own way to the breast.  Talk to your baby, stroke him and make eye contact.  Soon he will begin to bob his head and try to move down toward your breast.  Help your baby to do what he is trying to do but let him take the lead.  Baby may use his hands to help find the breast and may suck on his fist to calm himself along the way.  If you or baby get frustrated, just bring baby back to the position in which he is upright between your breasts and let him begin again.  Laid-back breastfeeding allows both you and your baby to rely on instinct rather than following prescribed steps for latching.

Feed baby as frequently as baby is willing, even if baby is half asleep. Newborns need to nurse 10-12 times a day or more to properly stimulate a good milk supply and to learn to breastfeed well.  Watch for feeding cues: rooting, squirming, rapid eye movements, head turning, hand to mouth movements, small sounds or sighs.  These cues mean baby is ready to feed.  Crying is a very late feeding cue and crying babies are difficult to breastfeed.

Begin hand-expression and spoon feeding if baby is not latching or not transferring milk within the first 1-3 hours.  If you are unsure that baby is feeding well, it is best to express some colostrum after feeds and give it to baby.  You will be able to express a few drops to a few teaspoonfuls in the first 3 days after birth.  On the first day, babies who are breastfeeding well, transfer between 2-10 ml per feed with 8-12 feeds per day, averaging 45ml total transfer for the first day.  If baby is not latching, hand-express at least 8 times a day and feed baby by spoon or cup. Do not use a breast pump until milk increases.  Breast pumps are not especially effective at removing colostrum and the vacuum can increase edema in the areola, slowing or stalling milk transfer.

If your areolas feel firm, use Reverse Pressure Softening RPS* (developed by K. Jean Cotterman RNC-E, IBCLC). Especially if you have had any IV fluids or pitocin, you may experience edema (retained fluid) in your breast.  This can cause pressure on milk ducts and slow or stop the transfer of milk.  Milk that sits in your breast signals the breast to slow down production so it is very important to relieve edema.  Reverse pressure softening moves this retained fluid back into the breast, allowing it to drain through the lymph system.   RPS also stimulates the nerves in the breast that signal milk to “let down” and will help get milk flowing for feeding or hand-expression..

Do not use a nipple shield!  Nipple shields can be useful tools for some breastfeeding difficulties, but they are not helpful in the first few days before the milk supply has increased.  Colostrum is much thicker than mature milk and is not easy to transfer with a nipple shield.  The shield also provides a firm sensation in baby’s mouth that is not similar to mom’s nipple.  It is better to hand express and spoon feed until baby learns to latch onto the breast.

If your nipples are flat or inverted, your baby may, but not necessarily, have difficulty latching at first.  If your baby is having difficulty latching, due to flat or inverted nipples, avoid putting your finger, a pacifier or a bottle nipple into baby’s mouth.  Do not bottle-feed or finger-feed.  Hand express colostrum and feed with a spoon or cup.  Stay in skin-to-skin contact and ask for help with techniques that can assist baby with latching.

Breastfeeding should not be painful.  If you are experiencing any pain, ask for help with baby’s latch and positioning.  Laid-back positioning usually results in a comfortable latch but you may need extra help.  Baby should release your nipple in a regular round shape with no pinching or discoloration.  If nipple is being pinched, feeding will be painful and nipple tissue may break down and crack.

If baby is not latching or breastfeeding is painful check baby for tongue and lip-tie.  This is a common reason for latching and milk transfer difficulties.  A simple procedure, called a frenotomy can be performed to help baby breastfeed more comfortably.

Baby should have at least 1 wet diaper and 1 bowel movement on day 1.

Day 2

Remain in skin-to-skin contact.  Expect to feed baby 8-12 times a day or more.  Your colostrum is available in small amounts, just right for baby’s tiny stomach.  Baby must feed frequently in order to properly stimulate a full milk supply.  On day two, babies who are breastfeeding well typically feed 8-12 times and transfer 5-15 ml per feed.

Baby’s weight loss over the first 24 hours may be influenced by IV fluids. If your baby has lost more than 7% of birth-weight at this time, it is likely that baby was over-hydrated at birth due to IV fluids given to mom.  This may be especially pronounced if mom was given 2L or more IV fluids.  This weight loss is not a reason to supplement with formula.  Continue to breastfeed or to hand-express colostrum and spoon-feed.

Baby should have 2 wet diapers and 3 bowel movements on day 2.

Day 3

Sometime on day 3 or 4, your breasts will begin to feel fuller. There has been milk in your breasts even before birth, but the birth of the placenta sends a signal for milk supply to rapidly increase.  The composition of the milk will change and begin to look more watery.  Most parents notice this increase around the third or fourth day.  Parents with gestational diabetes or who have had c-sections may experience a delay, of up to a day, before their milk increases.  Milk intake on day 3 will be approximately 15-30 ml per feed resulting in approximately 300ml over 10 feeds.

If baby is not directly breastfeeding, switch from hand-expression to expressing with a hospital grade double electric pump and use hands-on-pumping technique.   http://newborns.stanford.edu/Breastfeeding/MaxProduction.html  Express milk at least 120 minutes every day.  Express approximately 8-10 times a day for 15-20 minutes.  If milk volume has not yet increased, continue to hand-express in addition to electric pumping.

Skin-to-skin contact is still important.  It is especially important for the baby who is not latching but it is helpful for all babies while learning to breastfeed.

Lying back helps baby to latch more easily and to control increasing milk flow.  Many babies have difficulty adjusting to the increasing volume of breastmilk and laid-back breastfeeding helps them to have control over the flow of milk.

Avoid bottles if baby is not breastfeeding well.  Bottles require different tongue and jaw movements than breastfeeding and may make it more difficult for baby to learn to breastfeed.  Cup-feeding or finger feeding are options for feeding baby.

Baby should have 3 wet diapers and 3 bowel movements on day 3.

Day 4

You may be experiencing some engorgement.  Breasts may feel very firm and lumpy.  Frequent nursing, until breasts soften, can reduce the likelihood of engorgement.  If engorgement becomes uncomfortable or painful, cold compresses and ibuprofen may reduce inflammation.  Baby may have difficulty nursing from a breast when it is engorged due to firmness in the areola.  Use reverse pressure softening before breastfeeding or pumping to move edema out of the areolas and make them more soft.  Unrelieved engorgement may reduce milk supply so do not allow milk to sit in the breast.

If breastfeeding is going well, baby will have 6 very wet diapers and 3-5 bowel movements.  Bowel movements should begin changing to yellow and seedy by day 4 or 5.  Baby will be taking approximately 400 ml on day 4.

Day 5

Watch for signs that baby is getting enough milk.  Baby should lose no more than 7% of birth-weight, though some babies lose more due to over-hydration at birth if mom received IV fluids.  Baby should begin to gain 2/3-1 ounce a day starting on day 5 and regain birth-weight by 10 days to two weeks.

Watch for swallowing.  When baby latches, the first sucks will be quick and there may be several pauses.  When milk “lets down” baby’s rate of suckling should quickly become steady and slow to one suck per second.  When baby swallows, you will see baby’s jaw drop slightly every 1-2 sucks.  Baby should have a pattern of 10-20 swallows before taking a short 3-5 second break.  Baby should be spending most of a 15-30 minute feed actively sucking and swallowing.  If sucking is fluttery and quicker than 1 suck per second, baby is not transferring much milk.  Your breast should soften and baby should release the breast and seem satisfied.

Some newborns feed more quickly.  If your baby nurses for 10 minutes or less but is actively swallowing for the full feed, he may be getting plenty of milk.  However, the baby who swallows for just a few minutes and then falls asleep may not be getting enough.

Watch diapers.  Baby should have 6 wet diapers and 4 yellow bowel movements, at least the size of a quarter, every day after the 4th day of life.  Baby will transfer an average of 500ml on day 5.

Day 5-2weeks

You may still experience edema for up to two weeks.  Continue to use RPS to soften areolas if they feel firm.  If your breasts are pendulous, edema will collect in your areolas, so it is a good idea to recline, when using RPS.

Milk intake will continue to increase for the first few weeks until baby is taking approximately 750 mls or 25 ounces every day.   Babies usually consume 2-2.5 ounces of breastmilk per pound of body-weight, per day, until they reach an average intake of 25 ounces per day.  This intake is stable from 1 month until around 6 months.

If baby is not latching, or if you are having pain or low milk supply, consider hiring a Board Certified Lactation Consultant.  IBCLCs are the gold standard in lactation support and will help you overcome your breastfeeding difficulties.  You can also get help from La Leche League.  La Leche League Leaders are available by phone to answer questions and help you solve breastfeeding difficulties.

* See reverse pressure softening handout, developed by K. Jean Cotterman, RNC-E, IBCLC (mellomom@gmail.com)

© 2012 Laura Spitzfaden, LLLL, IBCLC