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I find my tongue tie resources out of date, though you can see my experience here.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.

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Not trying hard enough

Not trying hard enough is a phrase that has haunted me most of my life. For a long time it’s been applied vaguely at me in regards to weight loss. Despite my counting calories, and measuring or weighing most everything I eat and seeing no results. I bought into the idea that I must be doing something wrong and that I wasn’t trying hard enough. Now that I’ve finally (finally!) been diagnosed with PCOS I can give myself a little bit less of a hard time.

When breastfeeding went wrong and people actually said to me that I needed to work harder and that I wasn’t trying hard enough (also see: lazy, uneducated, and so on) I again bought into the idea that I wasn’t trying hard enough and it ate me up inside. I mean so many people were saying (mostly without knowing the specifics) that there must be something I was doing wrong.

Thing is, in a normal situation these things are not rocket science. They are simply not that hard. When you aren’t in a normal situation though, all bets are off. There are lots of variations on not normal, so be cool and give support.

This time around has been a really different experience for a lot of reasons. If I had more time I could write guides about horrible sleepy fussy babies with oral particular-ness and how much more this low supply gig sucks when you also have a toddler.  Most importantly though I know this time I am totally awesome and actually pretty damn hardcore for being able to do this.

I ran into some internet comments the other day espousing the same old tired bullshit that low supply is ultra rare and that people who say they have it are all a big bunch of lazy liars and blah blah blah. It made me a bit weepy because I’d forgotten how many of that type of ‘lactivist’ there still are. Here I’d been thinking that recent media exposure on the prevalence of breastfeeding issues had somewhat changed the landscape in the past two years. Ha, I say. Ha.

Someone else in the same stream of comments said something along the lines of ‘Well 99% of pancreases work so diabetes is ultra rare and you only think you have it’. Someone else countered with ‘Don’t eat 50 donuts a day and expect your pancreas to work’. I then thought, if anyone told a type 1 diabetic that eating donuts caused their disease they would just be convinced that person was a moron. Put it all in perspective for me. Anyone who ever thinks I didn’t or I’m not trying hard enough I can automatically dismiss as a moron.

Phew.

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.

 

Five days of faith

My anxiety over baby weigh ins is coming back. I’d more or less become at ease with having my toddler weighed until her last appointment. Here we have well child nurses who do the weighing and measuring. Most people seem to have ineffectual but harmless ones, a few people seems to have good ones, but mine is subtly malicious. I’d been putting off going for the 21-24 month check. I figured I was going to get a lecture on how bad it was for my child not to drink milk and another suggestion of doping the milk with chocolate or sugar to get her to drink it. Believe it or not I was told by a doctor to do that. Then I swapped doctors. Some kids don’t like cow milk and that’s ok. But milk is some kind of odd holy grail of child nutrition. Whatever. There are plenty of other dairy products and fats in her diet so I wasn’t worried about the lack of milk drinking, just annoyed I assumed I would have to sit through a lecture.

Boy was I wrong. When asked how much milk she consumed I said, none, she doesn’t like it. And I braced for the lecture that didn’t come. I was told that was ok. However, rather than feeling better my stomach dropped because I knew, knew, that the nurse was going to find something else. She always did. Every visit has been an exercise in criticizing something about my parenting.  So at the end of the visit there it was. ‘She’s too fat’. Cue jaw drop from me. My 12 kilogram (27 pound) 23 month old is too fat. I was instructed to stop giving her snacks and the usual anti-obesity advice about not letting her have soda or sweets. We’re a soda free household, child only drinks water, not even juice, eats reasonably well, e.g. not picky, only whole foods. As processed as it gets is store bought pasta. Needless to say I went home and cried. I may not have even made it home. I probably cried in the car.

But now, rather than being obsessed over her weight gain I find myself looking at her body, wondering where the extra weight is. Because she’s not even remotely a chunky child aside from toddler belly.  She’s a lot smaller than most kids her age even. I feel in some ways like my whole life with her has been an eating disorder by proxy. I used to have panic attacks before getting her weighed when she was a baby, terrified her weight wouldn’t go up and I would have to supplement more than I already was. I now compare her mentally to other children and I still can’t see anything wrong, but now I wonder if I’m just deluded. I hate it. I’m terrified I’ll let it slip in my attitudes or behaviors and she’ll pick up on it.

I wanted to enter this next baby’s life without that anxiety over weight. I knew I’d have to go through the 5 days of faith to see how milk intake and gain was going. But now I’m back to being a panicky mess over it. Back to where the thought of a weigh in makes me want to vomit.

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.

How to interview a lactation professional.

I’ve thought about this some, but then it came up in the comments for another post. A few of my posts reflect ideas I’ve had on this topic, so I’m going to expand on those as well as adding some new thoughts.

This should probably be broken into two groups: Prospective mothers (expecting), and/or those requiring generalist help and current mothers who have experienced a problem.

Let’s cover expectant mothers first.

If you are expecting your first baby, or your first baby you wish to breastfeed, you want to make sure you have an adequate amount of support. You should be focusing first on what resources are available to you.  This means checking with your hospital, your birth care provider, your pediatrician (if you are in the US for example), your local LLL chapter as well as seeing what private lactation professionals there are in your area. You should focus on how to access the services and what the cost will be to you. Having knowledge of where to find these resources is just as important as a birth plan, and for much the same reasons. The goal is to educate yourself to make informed choices. In addition, trying to find a lactation professional when you are desperate for help does not allow you to make informed choices. Try not to wait until you are desperate.

General questions to ask:

  • What are your qualifications? Here is a lovely guide I found on what all the titles mean.
  • How long in practice?
  • Is there any particular area you have additional expertise or interest in? (If you’ve got low supply and you are talking to a IBCLC specializing in oversupply she might not have the resources to give you the best help. If you are surveying what is available in your area then this is information worthy of noting down.)
  • What are your working hours? Do you work out of any hospitals or clinics?
  • What are your fees? What are your followup policies?
  • What breastfeeding challenges have you seen, treated, or overcome yourself?
  • Do many of your clients meet their breastfeeding goals?
  • If I experience a problem outside your area of expertise do you feel you have relevant resources to refer me elsewhere? What would you consider outside your area of expertise?
  • If I experience problems it will likely be a very emotionally turbulent time for me. Have you had experience supporting decision making and coming to a consensus about ways to resolve the problem (your provider should be willing to have a back and forth with you and if you decide that enough is enough support you in that as I refer to in this post).
  • What kinds of issues have been most difficult for you to help mothers and babies with and why? (as in, do they find the mother’s determination lacking, are surgical referrals difficult to get, etc. This is should act as a sounding board for their typical experience, if they have professional peeves as well as how understanding they may be to your situation)
  • How do you generally balance a mother’s well being with her initial desire to breastfeed? How do you manage situations that do not meet expectations and goals?

I also think that pursuant to this list, some of the general things you should ask a lactation professional if they have experience in are:

  • Do you have experience identifying lip and tongue ties, including posterior ties as well as other oral abnormalities like bubble palate? Are you confident identifying these types of abnormalities?
  • Do you have experience identifying a breast with  insufficient glandular tissue?
  • If you are a first time mother at risk for breastfeeding difficulties (PCOS, diabetes gestational or otherwise, history of thyroid disorders, lack of breast changes) you should certainly mention that. An appropriate response to my view would be a physical examination of the breasts as well as a wait and see with potential aggressive treatment if desired. Go the other way if you are told that any of those things will not matter.

Now for mothers who have previously experienced issues or are currently experiencing issues.

You’ll want any of the above that seem relevant as well as the following.

Specific questions:

Most of these are fairly situational so choose or adapt any that seem appropriate to you.

  • My issue last time was X. Will you help me explore solutions for that? How will you do that?

I’ve found some sounding board questions quite helpful to see how much recent research has been kept up with. You might ask if they know about the link between PCOS and breastfeeding issues, thyroid problems and breastfeeding difficulties, or even a more general tricksy question-what medical factors are you aware of that influence milk production in the mother and milk extraction or digestion in the baby?

  • What are your guidelines for supplementation in the infant.?

This is a personal preference one. The answers may range from over 7-10% weight loss, to watch the baby. I’d be wary if they say that supplementation is almost never necessary. If they say that I’d follow up with askance for some clarification i.e. in general or among your clients? What techniques do you use then for managing babies with milk extraction issues or mothers with milk production or ejection issues?

  • If supplementation becomes necessary which methods will you support me with? Are there any you will not support?

If you used donor milk last time and plan to should it become necessary again you’ll want a professional that supports you in that. If you used formula and prefer that, again, support. If you want to use bottles, you’ll want support in managing that, if you don’t you’ll want tips on other feeding methods.

  • As my issue was X last time can you give me some realistic expectations on what management of this issue will look like on a daily basis and what difficulties I am likely to face?

If they tell you you’ll need to pump 15 times a day as well as do some other things and this does not seem sustainable to you because of other children then bring that up. Discussion about an action plan is key.

  • Make sure to mention things you did or tried previously and whether or not you feel they worked as well as whether you’d be willing to do them again.

For instance, I tried domperidone and it inhibited my letdown reflex, and I am open to supplementing via SNS if it can be demonstrated to me that an oral abnormality is not the issue etc. You don’t need the frustration of reinventing the wheel and to avoid that the LC will need as much information as you can give her.

Warning signs:
  • Being told to wait and see or being told that every baby is different when you’ve experienced issues previously. Wait and see is a reasonable approach for some things but not if you want to be proactive. With some things it’s important to act quickly.
  • Your LC should never touch your breasts without permission.
provide support and encouragement to enable mothers
to successfully meet their breastfeeding goals

So if your goal is to breastfeed for 2 months then move to combination feeding for the next year she should be able to give you strategies on how to do that. She should also be supportive of your goals and willing to have an open and non-judgmental conversation with you. If your goal is to exclusively breastfeed with contraindicating issues she may (unpopularly) explain that that may not be possible, but give you long term management tips.

Note: there are a range of breastfeeding topics I do not have much experience with. Issues like oversupply, feeding multiples, flat or inverted nipples, breast size issues, prematurity in the infant, allergies in the infant, and reflux as well as others so I can’t give examples of more specific questions relating to those issues. However I can say that if any of your concerns are brushed off without explanation that is cause for alarm.
Overall you want to be having a conversation. Figuring out if this is the right person to help you if and when you need help.

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?

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.