When do you need help, and what kind do you need?

I found this interesting little scoring chart for self assessment and when to seek help. I mentally scored our first few weeks and came up with a score of 21. Low end of normal, me mostly getting points from my inherent nipple shape, and not having rock hard boobs, but having scores of 1 and 2 in multiple areas. I had 5 1’s and 5 or more 2’s. I think we can safely say that milk consumption by my child was an issue. But there’s not so much information on delineating milk transfer issues from milk supply issues. It seems there’s a lot of focus on either supply or latch and positioning. But looking at that list above I can mentally tick off causes for the troublesome symptoms listed, probable latch/oral abnormality issue, potential milk supply issue and so on down the list.

I was chatting with a woman months ago and she mentioned some really classic tongue tie symptoms: clamped nipple, serious damage and pain, baby losing weight despite her experiencing engorgement, baby who would only latch if propped up just the right way, and baby slipping off the breast. I said, tongue tie, get it checked, and go to a dentist if your LC doesn’t agree, here is a list of ones in your area. Here’s some pictures. She ignored me (as people do, after all, who am I?) because her lactation consultant focussed instead on propping the baby up just so, having the right amount of pillows, sitting just so in a special chair. So she was able to feed the baby with someone there to make sure everything was just so. Not so much when she didn’t have help. It still hurt, but it was tolerable. For a while. Then she started pumping to give herself a break. Then she had to do the whole song and dance over getting her baby to take the breast again. Finally, after several months of this she finally got a tongue tie diagnosis.  During this time she was concerned about her supply. Her baby wasn’t gaining quite right. I kind of wanted to bang my head against the wall and say it’s not your supply! Or at least it wasn’t… Ah well. It seems somewhat common to ignore the potential oral issue in favour of finding a positioning, or latch technique, fix.

Supply issues are a common worry. Here are some common features that low supply and milk transfer can share:

  • Long feeding times (in excess of 40 minutes with short breaks and few substantial sleep periods)
  • Poor infant weight gain, or loss
  • Poor infant output
  • poor infant test weight
  • dehydration
  • apparent lack of milk in the breast (poor engorgement, not full feeling)
  • Lack of appropriate sucking or swallowing motions (mine was a big flutter sucker)

What features are unique to low supply?

See, that’s the thing.  I can’t think of any that do not benefit from first ruling out milk transfer issues.  Low supply is certainly real, as well as more common than it’s made out to be, but a lot of the probable symptoms benefit from a wait and see approach (apparent tubular breasts or IGT), or can be caused by ineffective milk transfer. There isn’t a whole lot you can do before birth to assess probable low milk. Breast shape and placement are good markers, but breast changes from days 2-5 post-partum and physical examination of the infant for sucking ability are better indicators. Hence the wait-and-see.

So what features are more commonly associated with milk transfer issues?

  • Latching issues. Anything from slipping off the breast, to pain, to tissue damage.
  • infections or blocked ducts
  • nipple shape-coming out of the infant’s mouth compressed or inherently flat or inverted
Most breastfeeding assessment tools have audible swallowing as a consideration. I thought my baby was swallowing audibly, but it was a very quiet noise. I was told to listen for a ‘keh’ type noise and I did hear that, but it was infrequent and not associated with actual volume swallowing. I was also told to watch for muscle movement near the ear. Again, sort of saw something, but not really anything vigorous. A better diagnostic tool  is either watching, or (unless your baby is nursing upside down) putting a finger under the chin. The chin should be moving, and larger chin movements mean more milk in the mouth.
The take home message is if your baby is not eliminating, gaining, growing appropriately you should first rule out milk transfer issues.
So when do you need help and what kind do you need?
On call, wait and see type help during pregnancy:
  • When your breasts do not grow, become painful or otherwise change during pregnancy.
  • Flat or inverted nipples, large breasts
  • When you have PCOS, thyroid disorders or other autoimmune disease.
  • If you had a short luteal phase (8-10 days or less), excess spotting before or after menstrual periods. This is a sign of low progesterone.
These are all things that may be a risk factor, but may turn out just fine. You may want to discuss the issues with your chosen care person, but waiting and seeing is a good course of action. You should have an evaluation between 2-3 days postpartum to assess breast changes as well as a potentially earlier evaluation of infant sucking ability. This is in addition to the more standard 5 day weight check
What are you looking for? Breast changes, such as visible veining, becoming warm, itchy, heavy, swollen or engorged.
Active help which with you can discuss issues prior to the birth:
  • Any kind of breast surgery
  • Previous breastfeeding issues
  • Diabetic, gestational or otherwise
  • Other mother medical issues, or expected baby medical issues
Where should you get help?
This is highly variable. You need to find out, before you need it, what type of help is available to you and when. Will your hospital or birth place have a lactation consultant available to you? How is your local LLL group? Do they have resources for you? Are there breastfeeding support groups in your area? Make a list of private lactation consultants and call them to check their fees and help availability. If you want to rule out milk transfer issues I recommend finding a pediatric dentist or laser dentist in your area. Even an oral surgeon. Call them and ask about tongue ties, diagnosis, treatment and consultation. Focus on how you can access the services.
When you have problems:
This is where your handy list and pre-emptive work will be useful. When you do encounter issues, pain, excess weight loss and so on, you have a list of contacts. It’s much easier to put together that list before you need it than scramble around trying to find places to get help in the middle of your problem. Or with a newborn at all. And if you don’t need it, all the better.
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