A personal case study- a success story

A self case study on Metformin use in pregnancy and lactation outcome.

History: 35 year old female on 4th pregnancy with 2 living children. Previous low supply with undiagnosed cause. Child #1 needed 400 ml supplement daily (while using at breast supplementing device), child #2 needed 300ml/day. Child #2 was treated for ULT and PTT and mother did herbal regimen (including alfalfa, goat’s rue and others) during and after pregnancy with minimal improvement.

 

Lots of previous trouble losing weight. Prior to starting metformin normal but slightly high cholesterol, triglycerides and sugars. Always passed glucose tolerance tests. Started metformin (1500mg) when child #2 was 3-4 months old (approximately February 2013). Weight 110-115kg (lost 5kg by cutting down on carbohydrates).

Over the next year lost over 30 kg with minimal diet changes. Increased metformin dose to 2500mg/day.

Maintained this dosage throughout pregnancy.

Things I noticed during pregnancy:

Breast growth from 106cm at 5 weeks to 122cm at 39+2 weeks (delivery day). On day 9 postpartum breasts were 126cm in circumference, but have since reduced to 122 cm.

Significantly noticeable darkening of areolas during pregnancy. In previous pregnancy were only slightly darkened. Darkening faded somewhat toward 38-39 weeks.

Weight gain was slowed from previous pregnancies. Not much gain until 10+ weeks (previously up to 5kg gain in first trimester) and 15kg gain overall. Not ideal, but much reduced from 20-30kg gains experienced in past.

Morning sickness was lessened from previous pregnancies (all same sex), with much less vomiting and reduced queasiness.

Birth was elective c- section (previous two births were urgent/unplanned c-sections while in labour).

Overall summary and observations:

Baby gaining 100g+ weight per week from end of week 1 to week 6. Feeding, eliminating normally. Growth slow. Supply may be a bit low, but also have genetics for petite slow gaining babies as on demand supplementation hasn’t led to huge gains in the past.

This result required no pumping or other heroic measures. Just putting baby to breast on a 2-3 hourly schedule.

370g loss from birth to day 6, different scale variation at play as well. 700 g total gain by 6 weeks of age on the same scale.

Feel that metformin has made a noticeable difference in various ways.

Tongue tie was less significant and more easily corrected (75% anterior with thin membrane and little submucosal anchoring as opposed to two primarily submucosal ties in other children)

20150113_094902

Adequate milk supply for the first time across 3 live pregnancies

Food intolerances are lessened. Past babies had intolerances to brassica family vegetables (including mustard for one baby), gluten, citrus, tomato, garlic, onion and possibly other things. Only minor irritation observed in baby from onion and tomato (excess gas).

Weight gain was less- 15kg gained as opposed to 30kg and 20kg with other two pregnancies.

Colostrum was clear in previous two pregnancies, but was golden yellow for this one, though there were clear times. This may also be related to breastfeeding child #2 at least once 1-2 weekly until 38 weeks pregnant.

More normal post birth hormonal progression- feeling desire to have another baby despite not wanting one and so on.

No change in gestational diabetes status (negative all times). All other blood work similar to previous pregnancies (normal with minor low platelets).

 

Weekly logs of weight gain, breast and belly growth, other supplements taken and symptoms were recorded.

Self case study logs and notes

Case study data and graphs

 

So. I’m amazed. I have a hard time believing this is real. But things are going normally, and I’m incredibly proud of myself. Not because of breastfeeding, because honestly this current experience is much easier than my past two experiences, but because I figured it out.

 

I would certainly like to see clinical trials of metformin use in women with histories of insulin resistance, hyperinsulinemia, or undiagnosed low supply.

Executive Summary

I had a thought today that I would like to know the answer to. With so much publicized research being done on the properties of breast milk (antimicrobial, stem cell properties, brain development and so on), where is the research into real lactation problems? Where is the safe approved drug to increase milk supply (Metclopramide isn’t really ‘safe’ and Domperidone isn’t really ‘approved’), where are the actual diagnoses for supply problems? Maybe companies would rather head toward synthesizing the properties of breast milk rather than helping to fix bodies to produce it. After all it’s only several hundred thousand women a year, and formula does exist (my tongue is so far into my cheek it might poke through…)

I don’t know. I suspect there is not a satisfactory answer.

So I leave you with this. A short guide to various posts that are intended to be helpful.

I need help:

How to interview a Lactation Consultant

11 things a Lactation Consultant should know how to do (IMO).

Do I need help?

I find my tongue tie resources out of date, though you can see my experience here. For better information I would urge joining this Facebook group. They maintain lists of providers and are fairly knowledgeable about what is to be expected. If a provider is not on their list people can often recommend local alternatives (for instance I know of at least 4 laser tongue tie release places in New Zealand now, but none has made the general list. Do see the New Zealand Tongue Tie resources page instead.)

I need to combination feed-how do I do this?

The big fat Combo feeding FAQ

Walking the line

Benefits of

With low supply

SNS tutorial

Nipple confusion

Managing long term

Formula

Solids

Weaning

Body Image

What is causing this?

Able

Potential causes

Birth complications

Rare vs Undiagnosed

My most popular post

Making Milk beads

And the rest of my life.

I think I no longer feel bad, because it isn’t something I did wrong. It’s purely a medical issue.  A medical issue that some people would have me believe is my fault. A medical issue I cannot get satisfactory treatment for and that is largely undiagnosed. That makes me mad.

I lie. I still feel bad and somewhat inadequate, but I no longer feel guilt. I do wonder how much of my feeling bad is a normal level for someone suddenly faced with a non-life threatening failure of a body part. Somehow I can’t imagine people feel a mix of loss of gender identity and self loathing after losing a kidney or having a splenectomy. Or losing a finger or a limb. I’m sure there are other mixed feelings but I wonder how often self hatred/loathing/failure is a part of that.

Cooking with Milks

Another consequence of my second child being such a fuss butt was that when I went back to work she refused a bottle. I feel like a meme belongs here.


Anyhow, in two children I’ve learned to use up my milk. It was hard to come by, be damned if I’m going to tip it down the drain.

Milk jello.
This sounds so grody, but it’s a reasonable option. I tried it first with formula, but it will work well with expressed milk too. A half and half mix with powdered or concentrated formula will likely work best for technical reasons.
Add gelatin to boiling water and dissolve. This is the technical reason I mentioned. Gelatin dissolves a lot slower in milk than water. So you could boil your breast milk and dissolve gelatin into it. But it will take longer. Add appropriate amount of formula for the amount of water the gelatin is dissolved in. Add your milk. Pour into containers and allow to set. I found 14g (1/2oz) ad 200ml far too firm. My baby could pick it up but couldn’t really suck bits off. I doubled it (you can melt it back down in a double boiler set up. If you don’t have a double boiler a frying pan with water and a pot in that will work just fine) and it was still a bit too firm. Follow the directions on the package. Use within 3 days.

Milk custard.
One version requires your child able to have eggs so after solids are more established perhaps. You can omit the egg and make the custard more of a roux instead though if you do that I would definitely make it in a pan stove-top.
The smallest amount is about 100ml of milk, 1 egg yolk and 2 tsp of corn flour or corn starch(I wonder if you could use tapioca/arrowroot or other flour for this instead). You can even do this in the microwave. Mix ingredients and whisk. Heat for 1 minute in your microwave and whisk again. heat for 30 seconds and whisk again. Repeat until it starts looking thicker around the edges. It should be setting up by this point. If doing in a pan just heat and whisk until setting up. Cool and serve or put into containers to set. To double it use 200ml milk 1 egg yolk and 2-3tsp flour. After that you will need another egg. Also more flour. Feel free to add extras-fruit, sugar etc. This was intended to get fluids into my non-drinking kid so I started out with basics. Keeps for 2 days.

Muffins
This is what I did with all my lipasey milk from my first child. She wouldn’t drink it so I baked with it.  I also made some jewelry…

Anyhow.
1/2 cup flour, 1 small egg, 1/2 cup milk, 1tsp baking powder, 1 tbl oil and whatever fruit, spices and extras you want to put in there. This recipe doubles as a pancake recipe. Our favourites were apples and cinnamon, pumpkin, lemon zest, berries etc. Keeps for up to a week and can also be frozen.

Human milk proteins, carbohydrates and fats are still good, so if you need to use up some old or slightly off milk cook with it. I use these techniques on milk that for example is lipasey, has not been drunk all day at daycare etc.

We also found soaking some bread in the milk worked well. Pretty much the cereal principle, but for the Baby Led Weaning self-fed child.

After 3 weeks of fussing, losing weight and playing around we found a sippy cup (just a cheapo plain one) that she would take that made daycare happy. But I’m still pumping milk and occasionally need to use some of it for non-drinking activities.

The great tongue tie caper


Or how I feel like I stumbled into a cult.

I mentioned my second child having a tongue tie previously. Well after the snip with the scissors I was still having pinchy latch feelings  as well as latch slipping and I knew the lip tie was still around. After wondering about long term management of my not entirely tongue tie related low supply problems on the MOBI message group I was prompted to revisit my research  into laser release.  I emailed them and asked if I could send along some pictures and see if they saw any problems.  They did. So in a whirlwind I made an appointment to see them, booked flights and planned a 12 hour day in Auckland with a 3.5 week old.

We flew up there, I found where the place was and I proceeded to hang out. This baby is incredibly laid back and sleepy, so armed with a baby carrier there was no problem.

Here is the lovely park we spent far too many hours at.

 

I’m glad it was a nice day.

Anyhow, the Laser procedure was fairly straightforward. The Doctor/dentist was nice, his staff was nice as well. The whole thing was very posh. Posh is a good word. It was really over the top for me. I felt a bit grubby in my jeans and sweatshirt next to the fleet of designer suited office assistants in an obviously expensive office block. The procedure was also quite expensive. But I rationalized it by thinking it’s about the same amount some people spend on a designer stroller or a smartphone, and this is more beneficial. Well at least I hope so. I still feel several weeks after the procedure that the whole thing is a bit faddish and people’s behaviour is a bit cultish as well. Oh, no doubt my child had a tongue tie and a lip tie. And no doubt many people who also have tongue and lip tied children have much more severe symptoms than we did. The ties didn’t hurt me that much, though they were a bit uncomfortable. I didn’t have anyone doing test weights so how much they helped milk transfer is debatable. It certainly didn’t fix everything. But I still feel vaguely taken advantage of.  Preyed upon even. Us poor women with breastfeeding problems doing everything we can to make it work. Not necessarily by that doctor, but in general. My midwife is a bit displeased I went ahead and did the laser. She thinks I’ve been taken in by a fad. And maybe I have been. We plan one more child and right now I can’t say definitively that I would do the laser again. Or if I’d have it done for my older child. I know for some people the result is unquestionable, but for us, not so much.

There’s a huge hole in terms of what most professionals will or can treat and it’s being filled somewhat by self diagnoses and things that are expensive with dubious benefit. And I’m finding the associated peer support a bit questionable as well with certain things that must be done and it’s sort of like if you aren’t doing the whole laundry list then you have only yourself to blame when things don’t work out. I’ve found myself at odds with others in this situation before. I do draw a line as to how far I am willing to go and for some that makes me less dedicated, but I also go further than many others do and for some that makes me a tad bit crazy.

Anyhow. Here are the before and after pictures of the tongue and lip ties.

Lip tie

Tongue before scissors

Tongue after scissors

A few days after lasering

Lip tie

Tongue

A week after lasering

 

 

Why a correct diagnosis is important.

Or how wait and see doesn’t cut it.

For the first 8 months of my first child’s life I thought I had low supply, probably from insufficient glandular tissue. I wanted a definitive diagnosis though and couldn’t find anyone to give me one. Then around 8 months, after we’d transitioned to just solids and breastfeeding and put the SNS away in the closet I noticed something that led me to believe that a posterior tongue tie might be the real problem. I couldn’t get a diagnosis for that either, but the more I read and researched a tongue tie did seem to be present. That discovery filled me with hope. Hope that next time would be different, that there was something I could do to make things better. So I planned my next breastfeeding experience around that. I lined up tongue tie release, made my midwife aware of my history and suspicions and mostly did as I was told- to wait and see because this time things might be different. I was told different child, different mouth shape, maybe no problems this time. I was dubious, and didn’t use as my midwife anyone who refused to take my concerns seriously, but I did get some variation of wait and see from everyone I talked to.

Just to hedge my bets I drank various teas throughout my pregnancy and made all my postpartum meals full of lactogenic ingredients.

And then I had my second baby, not how I planned, in fact things went in a way I hadn’t thought to plan for, but I had her and it was ok. Not great, not bad, but ok. And there was an obvious tongue tie, not a posterior one, and there was some waffling about whether it would cause problems from the hospital lactation consultants, and my midwife went to bat for me and we got it snipped anyhow. It made the latch a bit better and things were going normally. We were proceeding with caution, and I was getting some varying opinions on whether intake was good. Some people said looks good, some people were concerned about swallow frequency. I was a little stressed out, but I was assured that if I hadn’t had any history that no one would be worried. I was cautiously optimistic. Things were already different and better by leaps and bounds in terms of latching and output and weight loss.

After 5 days we went home. My milk came in, though there wasn’t engorgement as such, just a feeling of fullness and heaviness. I wasn’t too worried. After all some women don’t have much engorgement, right? Yes, but. Be concerned when you keep running into signs and symptoms that by themselves don’t mean much but when accumulated paint a more dire picture.

We’d had 8% weight loss by day 6. Well within normal ranges. Considering last time we’d had 11%+ by day 5 and more after that, 8% was fantastic. Output was good, my optimism was increasing. There was still concern about swallow frequency, but things seemed to be going well.

By day 11 only 60g (2oz) had been gained. Normal newborn weight gain should be at least 30g/day. I’d been expressing milk on top of feeding to boost my supply and to give as top ups to combat the cluster feeding. My midwife wanted me to get more than 2 hours sleep per day to help my milk, and also because having a toddler and a newborn isn’t sustainable on 2 hours of sleep out of 24.

The baby was sleeping more and more. We were feeding on demand, but where #1 had screamed and cried and never slept unless held, this one would sleep for 4+ hours, fall asleep at the breast and was generally very lethargic. I was pumping 4-6 times per day on top of feeds, and giving that milk via the SNS. Output was still good.

And day 15 came and the weight was the same as at day 11, 210g below birth weight. And the baby was so lethargic at that point that getting her to take a bottle was over a 1 hour affair of cold cloths, stripping, changes and so on for 60ml consumed.

So now we went into disaster management mode. I was to give 60-100ml via bottle every 3 hours day and night and pump afterward. We practically have to force feed the baby at this point.

It’s been a few days of that and hopefully birth weight will be regained in another day or two and we can revisit other feeding options, or even go back to feeding on demand.

And that’s where we are now. I wish we’d known before that IGT was the issue. I wish I’d been able to get that diagnosis. I could have been using the SNS from around day 10 or before and doing test weights to measure intake rather than disaster management of a lethargic and dehydrated baby.

Now I’ll likely have to contend with nipple confusion, breast refusal and possibly losing any kind of breastfeeding relationship. I might still be able to pull this situation out of the fire, but a diagnosis last time would have made this easier.

 

Postmortem

I’ve been thinking about why some diagnoses make sense for me and others do not.  I’ve done mental lists before but I think it’s past time I did a postmortem analysis of my breastfeeding experience. Not that it’s dead just yet…

My midwives told me that it was my supply. So I pumped and I pumped, and I fed and I took herbs and domperidone… and it didn’t really seem to help. For a long time I thought baby not getting enough milk to gain weight or poop, and I can’t pump it out means it’s not there, right? Not necessarily. When my daughter was around 8 months I noticed a lip tie and read about the correlation between that and posterior tongue tie. So then I thought that was the issue, but I can make some points in favour of several causes.

I’m not sure the best way to group this. Maybe a reason for, reason against section for each suspected issue.

Symptoms in support of IGT:

I have breast asymmetry. It’s fairly noticeable. I also have stretch marks, though I’d assumed they came from puberty. I actually remember the time when my left breast grew bigger than my right. I was probably about 12-13 (I was in junior high because the memory includes wandering around that day in the halls with my hand clamped over one breast because it hurt so badly). I just remember it being painful.  My breasts look a lot like one of the pictures in the MMM book.

I don’t think that I had engorgement after birth. I did have a bit of warmth and itchiness, but not the hard breasts my midwives led me to believe I should have. Which is false anyhow, not all women have that symptom even with a normal supply.

Symptoms against IGT:

My breasts have always felt fairly glandy. If that’s a word. They aren’t very soft, instead tending to be firm. I’ve noticed them floating in the pool for the first time since I’ve had my baby.  I’ve never really gained weight in my breasts and they don’t seem to be primarily fatty tissue. As I said, glandy. I was always good about getting my yearly exams when I lived in the US (things are 3 yearly here if everything’s been normal, which it has for me), and that usually included a breast exam. You’d think someone (one of the at least 5-6 different doctors I’d had do breast exams) would have said something if there were not much tissue there… Then again, maybe not.

I tended to leak. I mean, not buckets, but changing my baby in the middle of the night, her crying would give me a wet shirt. Easily 5ml from one side and maybe 2 from the other. Also sometimes when I was feeding the other side would leak. Not enough to collect, or really  need pads, but enough to be messy.

This is a bit odd. I have some extra nipple tissue on one of my areola. So, while my breasts were not really engorged, that area swelled up like a blister. It got about peanut-in-the-shell sized.  I could get milk out of it, but it wasn’t easy. Apparently it was connected to some ducts as well.

When I was in the hospital after giving birth I had to hand express some colostrum. My baby would not initially latch well, she couldn’t open her mouth wide enough and when I tried biological nurturing style she shredded my nipples and gave me hickeys, preferring to latch onto any surface she could like a little suckerfish. Anyhow, as I was hand expressing colostrum the hospital midwives commented that at least my supply wasn’t a problem.  I know that colostrum production and milk production are not necessarily related (that is amount of colostrum does not indicate amount of milk), but it’s always made me doubt that supply was my problem, even when I was told it was.

While I don’t think my breasts did grow much during pregnancy and after, I know they did because bras from before pregnancy (still) don’t fit me. Also I had significant nipple pain during the first trimester.

I have had engorgement before to the point that one (just one, the other one has more fat on it I think) breast looked like a sack of peas. I went 15 hours without feeding or pumping when I had to travel for business. I had been accustomed to going 10-12 hours without pumping at that stage (my daughter was 11-12 months old), but the extra few hours made a big difference in comfort.

Symptoms for undiagnosed tongue tie

My baby has a lip tie for sure. She also was not able to hold herself on the breast until she could do it with her hands at over 6 months old. So I had to hold it in her mouth or it would fall out. Pacifiers (dummies) fell out of her mouth.  Even now she either holds them in with her teeth or her hand. Not that she’s much of a fan, they are more something to bite. She would leak milk when drinking from a bottle. She shredded my nipples early on. It wasn’t until 8-10 weeks that I didn’t look like ground meat from the cracking, and all the missing bits grew back. With some improvement in latch technique it didn’t hurt much after about 2-3 weeks. I did have nipple creasing for months. Since she got her upper front teeth I’ve felt them digging in to me somewhat, and she does leave little tooth indentations on me.

Her tongue has been forked in the past. As she gets larger and stretches it the fork has significantly lessened. For a while she was not able to touch her upper lip, but now she can. Nowhere near touching her nose, but she can now get the tip of her tongue over her upper lip.

She does have a ‘fence’ in her mouth per the Murphy manuever, though I can’t use Dr. Kotlow’s method of checking since it’s now a game to bite me when I try to feel what her tongue is up to.

When she touches her tongue to her upper lip the floor of her mouth tents up (as does mine…), and the sublingual salivary glands stick out (again, as do mine).

She has only rarely drained the breast, though that’s hard to gauge because my breasts don’t ever really seem to go totally soft because of the glandiness.

Symptoms against undiagnosed tongue tie

She has a pretty mobile tongue. I don’t see much inhibited movement to be honest, though I’m mainly comparing to myself, which is not a fair comparison, and she has been working on it as I try to gauge her tongue mobility by making faces at her. Perhaps it’s improved as she’s gotten bigger. She doesn’t have much in the way of frenulum either, though I know with PTT that can be the case.

Symptoms for PCOS related complcations

I suspect my grandmother had some form of PCOS. She told me she got her period at age 10. I got mine at 11. I have elevated androgen levels and issues with carbohydrates and my weight. If I do have some form of PCOS the onset was when I was around 20. One lactation consultant told me my issue was probably PCOS related (no breast exam for me, no oral exam for the baby though).

Symptoms against PCOS related complications

I have completely regular periods (I’ve been irregular twice I can think of and once was after a miscarriage). A lot of doctors have hinted at PCOS, but no one has ever felt able to make a diagnosis. While I do experience mittelschmerz, no cysting has ever been observed during ultrasounds.

Other ‘what does it mean?’ issues:

I was living in an agricultural area before and during puberty. I had also been consuming large volumes of soy products (dairy free from 8 to 13, then dairy and soy free) and been put on various calorie restrictive diets by my family from age 8 including a diet from age 13 to 17 that did not allow me to eat sugar, wheat, dairy, soy (as I had developed an allergy), any fruit other than grapefruit and lemon. I also experimented with veganism during this time (though that didn’t last long). I skipped a lot of meals, not eating for up to 12 hours at a time (sometimes longer) until I was in my early 20’s.

Fenugreek did not work for me. I couldn’t take enough to get the ‘smell’ and I didn’t see any difference with the amount I was taking (up to 12 pills daily. I also tried spoonfuls of soaked seeds as well as fenugreek seeds cooked with barley and tea made from a spoonful of seeds). Domperidone seemed to decrease my supply, or at least my let down. Blessed thistle made it so I did not have to supplement at night times and fennel and oatmeal were some of the more helpful things I tried. Anise seed, licorice root, red clover and nettle were also helpful. Vitex increased my supply, though I didn’t try it until after 12 months.

I’ve been lucky enough to have a fairly robust, if apparently insufficient,  milk supply. Since pumping at work and altering my pumping schedule until I no longer pumped I noticed that it would take at least a week to stop feeling discomfort from a missed pumping session. I only ever pumped 30-50ml per session combined. I expect the 18 hour per day feedings and excess pumping in the first 6 weeks helped me lay down adequate prolactin receptors so that my supply remained robust.

Prior to getting pregnant I had been having 9-11 day luteal phases with spotting before my period started, which can indicate a hormonal issue. However, this was for the months in between a miscarriage and getting pregnant with my daughter. I had not previously experienced much spotting before starting my period. I do expect that a 10 day luteal phase is more or less normal for me though.

I didn’t get my period back until nearly 16 months postpartum, and only after much cutting down on breastfeeding. I make the supposition that the inefficient sucking, as well as the numerous night time feeds,  delayed it’s return because sucking stimulation releases the oxytocin which inhibits menstruation.

Oh, then there were the array of potential medical issues. I lost 600ml of blood, which is within normal for a C-section, but if I recall correctly over 500ml can cause issues in some people. I had an emergency c-section. I was overhydrated both before and after birth because of my blood pressure being so low (to the point of breast edema, though it didn’t delay my milk, which came in, such as it was, on day 3). I had low platelets. Not dangerously low, but enough to be mildly alarming. I had been taking iron pills in my second and third trimester, but had run out early in my third trimester and my midwives didn’t think to give me more. So I could have been anemic.

The root of the 1% myth

I finally found the research that is behind the statement that 99%, 98%, ‘almost all women’, can breastfeed. It’s contained in a WHO report from 1989.

In the report nearly 4000 women from Nigeria and Zaire, as well as 450 from Guatemala are followed. No lactation failure is observed. You can read it at the link above.

Here’s my problems with the study in comparison to our industrial world.

Ancestral diet: In pre-industrial societies the population is more likely to be eating what they have been eating for the past several centuries. This means allergies are more likely to have worked themselves out of the population. Us in the western world? We’re eating sugars and processed flours and food additives, colors and dyes and flavors, not to mention foods our ancestors didn’t eat.

Genetic diversity: People in the USA, New Zealand, Australia, Europe, the UK and similar countries are less genetically diverse than African populations. However, this African genetic diversity is cluster or tribally based and not the hybrid mix that is found in the Western/developed world. That is, while many variations on the theme of humanity are present in Africa, they are not mixed as much as might be found elsewhere in the world. This means that while the populations are diverse, each individual population has gained genetic stability for issues like tongue tie and PCOS. Possibly to the point that these issues have been, to some degree, bred out of these populations. (See the comments as there are some important clarifications discussed there)

Chemical exposure: In industrial societies we’ve had decades of being exposed to endocrine disruptors, pesticides and industrial toxins. This means we are more subject to the things that go along with that, like endocrine disorders, autoimmune disease, and genetic mutations.

Modern medical science: We now have women surviving childbirth who may not have without modern medicine, and likely would not in a less developed country. The 2005 WHO report indicates a ‘natural’ childbirth mortality rate of 1-1.5%. This includes issues like high blood loss (a factor in lactation failure), postpartum infection (potentially as a result of retained placenta, another potential lactation issue). We also have women conceiving who may not have in the past.

The 1989 study above puts the blame on psychosocial factors for women not breastfeeding and seems to imply that all lactation failure is a result of perceived insufficiency rather than actual issues.  In addition it makes the assumption about the nearly 4000 African women that secreting milk=enough milk to sustain the infant. For the Guatemalan women the 448 are over an 8 year period and apparently all living children were all successfully breastfed. I’ve mused before that the 98-99% is potentially the percentage of mothers unable to secrete milk at all. A figure that meshes well with the ‘natural’ childbirth mortality rate incidentally. Or unable to physically put the baby to the breast due to serious medical issues like postpartum cardiomyopathy.

All of these factors contribute to a higher rate in developed countries. Simply put we are not women living traditionally in Africa. The differences between the populations considered are of considerable significance. The psychosocial factor is of importance, but for those who did educate themselves, did ‘do everything right’ and still experienced issues, it is clearly not the only meaningful factor.

Being better at baby friendly.

When I was pregnant I was pleased to learn that every hospital and maternity centre within reach was baby friendly. By that I mean BFHI accredited. I was pretty set on breastfeeding and I’d heard too many tales from acquaintances in the US and elsewhere who had had to fend off staff with bottles of formula, or who’d had bottles given to their babies as a matter of course. The way New Zealand implemented the BFHI has been of some interest. The number of BFHI hospitals here is much higher than in similar OECD countries. New Zealand has 72 as of 2010, or over 90% of it’s maternity hospitals, where the US has 119 , which is less than 5%, and the UK has around 52, or less than 20% of it’s hospitals.  Small country advantage, clearly.

Here’s what the BFHI is:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within one half-hour of birth.
  5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breast milk, not even sips of water, unless medically indicated. (this is for staff)
  7. Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. (this is for staff)
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The program also restricts use by the hospital of free formula or other infant care aides provided by formula companies. (Definition shamelessly stolen from wikipedia)

That’s all really. Now, of those 10 steps I can say I personally experienced 6,7,8 and 9. I probably would have seen 4 as well if I hadn’t been groggily recovering from my (non general anaesthesia) emergency c-section. When I was aware I wasn’t in the operating theatre and able to ask for my baby she was handed to me and I was helped.  I was also summarily helped most (but not all) of the other times I asked for help during my stay. So halvsies on number 5 then because no one ever showed me how to pump. I was also given a cartload of flyers so I guess that’s the effort for number 10 there as well. So 4 fully out of 10, with an additional 2 tacked on the end and one which probably would have been done had circumstances permitted.  The other 3, 2 really aren’t about me, they are about staff, and the third wasn’t an issue as I was already intending to breastfeed.

Why I think the BFHI is a good thing:

Those first days are important to teaching the baby how to suck from the breast appropriately. Giving bottles or soother devices when not medically indicated can cause issues like flow preference and nipple confusion which can be a challenge to overcome. I think if women do want to breastfeed they shouldn’t have to worry about what the staff are getting up to in terms of accidental sabotage.

In addition, the first few hours are regarded as critical for longer term breastfeeding success.

It does increase breastfeeding longer term rates. No question, there are many countries with success stories. If you don’t want to breastfeed you are able to bring your own feeding materials, and if you change your mind you are often not in hospital for very long. Our usual stay here is 48 hours for normal vaginal deliveries and 96 for caesarean. Complications like excess blood loss or surgical vaginal deliveries merit additional time. If you don’t want to breastfeed or suspect potential complications I’d urge anyone to get a copy of the hospital’s written infant feeding policy. Actually, probably it should be required reading for anyone giving birth, but that’s probably above and beyond what most people are interested in doing in terms of informing themselves. After all if they are BFHI they have to have one that they give to staff.

Where I think the BFHI needs work:

  • The quota system: Part of the BFHI is that to maintain the BFHI designation (and often the extra funding that goes along with it) BFH institutions must have at least a 75% breastfeeding initiation (discharge?) rate. This effectively turns front line staff into sales people selling breastfeeding to mothers to keep their institution’s funding. Can sales and support really be the same thing? I’d kind of think if you implemented the rest of the guidelines sensibly that the increased breastfeeding rates would follow without any uncompromising push from staff. Many people do actually want to breast feed. Really. But if they don’t, it’s less energy all around to just leave it. Give more flexible limits (apply the ‘quotas’ to only healthy singleton term infants, or have different quotas for mothers and infants at risk of lactation failure) to hospitals dealing in more complex cases.
  • Points 1 and 2. The staff training, which is where the implementation of the BFHI can go awry, needs better minimums or at least better standards. What goes into that staff training exactly? Is the training the same kind of overzealous lactivism that is used on women to push breastfeeding or is it something more along these lines? I find some of these scripts useful and some of them pretty objectionable.  Right now the minimum staff training for BFHI accreditation for nurses and midwives is 18 hours (I’m not clear if this is yearly or once ever), and for non nursing staff, so obstetricians, pediatricians and similar, is 3 hours (this is per year). The article referred to above (here it is again) outlines a lot of the issues with getting and keeping everyone trained. No wonder then that the result of the training seems to often turn front line care providers into walking breast is best posters. Which, you know, I’ve never seen? I did see a lot of breastfeeding posters at my various stays, but they were about gauging infant hunger cues, appropriate bodily output for the breastfed infant, signs of dehydration, and latching technique. So, more helpful things instead of useless platitudes.

I think this is the most telling quote from the article:

…specific resources and training may need to be provided for birthing centres that deal with complex cases where exclusive breastfeeding may be less likely to be achieved.

  • Point 3.  Misinterpretation of the guidelines. This is such a recognized issue I found a PubMed article about it. Being baby friendly does not disallow use of formula or information about formula. There are two main goals, one of which is to stop the free and low cost formula from being marketed to hospitals. The other is to protect breastfeeding by following the 10 steps for accreditation.  Because of the tie to certain numbers of breast feeding rates that I outlined in my first objection the guidelines are often exploited by staff.
I guess what I’m asking is if the education of front line staff  is adequate to have women’s experiences be more positive. I don’t think it is.  More interestingly, what goes on in those 3-18 hours of staff training? Is is a seminar with dire warnings about breast being best or is it something more informative, like infant stomach size marbles and spotting potential issues?
I’d imagine the 15 hour training time difference for primary support staff does have some more practical help with latching and positioning. But what about informing mothers they are at risk of lactation issues? Those with high blood losses, C-sections and similar? Gosh, what about tongue tie or IGT screening while we’re wishing? I think they must have some leanings toward that here as I had a lactation log card I was given to be filled out for feeding times and durations. I saw the writing on mine and though I dutifully filled it out my milk status was written on there for various days without having consulted me at all (colostrum, filling and full when full didn’t ever really happen). So even in fully compliant institutions there is some data fudging to get people out the door.
So, what should front line staff be taught?

Oral confusion-how nipple confusion works

Let’s talk about nipple confusion. Wherever anecdotes are valued as useful you’ll find plenty of stories that illustrate either view on nipple confusion. Babies who were given bottles early on and the mothers who had huge struggles getting them back, if ever, to the breast, as well as those who routinely gave their babies bottles and never had any issues at all.  So what’s the deal with nipple confusion? Nipple confusion is a collective name for something that is a combination of factors. Side note: I found this article, which looks like it would be a fantastic resource. Unfortunately, like many of Dr. Neifert’s articles, I can’t get electronic access to it (even at work where I have access to all kinds of journals). I’m sure that would pretty much replace my little post here, but since I can’t read it, I’ll just write this instead.

Teat Confusion:

First off there is teat confusion. How something is sucked. Babies are crafty, tricky little beasts. It’s part of their biological programming to experiment and problem solve in order to figure out how to best get milk out of breasts.  So teat confusion can arise from bottle teats and pacifier teats. Bottle teats as the method of getting fluid out of a bottle teat is different than out of a breast (see Myth 15 and associated citations). With a breast the mouth needs to gape wider and the tongue move to extract the milk via a peristaltic action. So undulation of the tongue.

With a bottle, the mouth does not need to open as wide and the tongue does not need to move out to extract the milk, but instead stops the milk from running down the throat too fast.

With a pacifier the method of suck also can effect musculature changes and the pacifier is inherently a non-nutritive sucking action. So the baby will do it because they enjoy the action of sucking. Something they are also biologically conditioned to like. With pacifiers there is no reward for improved technique (as with breast and in some cases bottle feeding) and the sucking action does not train the tongue appropriately. In addition the baby may associate sucking with no reward and be less enthusiastic about trying their luck with sucking from the breast.  With normal breast feeding let down can take a short while to start, so a baby who is conditioned early to suck an artificial nutritive teat may lose patience with waiting for letdown to produce milk

Flow Preference:

Another factor in nipple confusion is flow preference. Bottles have different flows, slow to fast. Not all slow flows are created equal as well. Probably each bottle/teat type is slightly different. So if a bottle, which has a different sucking method required, produces a faster, more generous flow of milk, or conversely a slower and more manageable flow, then the infant may find that preferable.  There is evidence that bottle fed infants suck less frequently and in different patterns than breast fed infants. Flow from the breast changes over the duration of the feed and a bottle is constant.

Latch:

The main factor in nipple confusion, however, is how good the latch is. The better the latch, the less likely the infant will experience nipple confusion. So babies with tongue ties or other oral abnormalities, or who have mothers with difficult nipples, will exhibit higher rates of nipple confusion signs. In addition to these conditions often producing issues with appropriate latch and milk extraction, often resulting in early bottle use, extracting food from the bottle is often easier for those without a normal range of oral movement.

Time sensitive:

Another factor to consider is that nipple confusion may not be immediate. I found when I needed to start combination feeding that while things were fine at first with supplementing by bottle, starting at 5 days with expressed milk and moving to formula by 2 weeks, by 4-6 weeks we had had some strong instances of breast refusal. This goes back to babies being tricky beasts. They start learning that if they fuss or refuse the breast that they can get some other potentially easier food. The most common ages for breast refusal due to nipple confusion or flow preference are  under 1 week, 2-3 weeks, 6 weeks, and 4-5 months. These coincide fairly consistently with growth spurts.

This is why it is recommended to not introduce bottles or artificial soothers before 4-6 weeks. By that age it’s assumed that the infant will have figured out milk extraction from the breast and will be less inclined to prefer the bottle over the breast. In addition, the mother’s milk supply will have begun to stabilize and a missed feed here or there under normal circumstances will not unduly affect supply. This guideline obviously errs well on the side of caution.

Prevention:

When you need or want to supplement with breast milk or formula and you want to minimize nipple confusion there are a few ways you can do this

  • The bottle latch: You’ll need a wide base bottle that encourages a wide opening of the mouth. Choose the slowest flow teat you can find to start with. Here is a  guide on choosing a teat. Purely by chance we used the Avent newborn flow. We used these until 12 months of age.
  • Finger, syringe, cup, and spoon feeding. Of these finger feeding may be the least pain in the ass. I’ve done both syringe and cup, as well as suck training with my finger and finger was by far the easiest. I’d imagine spoon feeding is similar to cup feeding in mechanism. This article sums up alternative feeding methods well. It says that cup is often not worth the hassle unless repeated supplementation is required more than 3 times. You can also use an at breast supplementer taped to your finger.
  • At breast supplementation: If you have a latching baby under 6 weeks this is the way to go. After 6 weeks if you have not yet experienced any latching issues or breast refusal you can try bottles. If you have been using bottles up until now and your child is not  yet at that grabby phase you can give this a go. Some babies are ok with it, some hate it. It’s just something to try.

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.