In the United States, Surgeon General Dr. Regina Benjamin released a statement in support of World Breastfeeding Week stating that, “one of the most highly effective preventive measures a mother can take to protect the health of her infant and herself is to breastfeed.” Earlier this year, Dr. Benjamin released the Surgeon General’s Call to Action to Support Breastfeeding which outlined
steps that can be taken to remove some of the obstacles faced by women who want to breastfeed their babies.

Here in Maryland, the Maryland Breastfeeding Coalition will be sponsoring or participating in several activities in support of breastfeeding including a Family Mall Walk at Annapolis Mall in Annapolis on August 3 at 8:30 am, and Baltimore WIC World
Breastfeeding Week 3K Walk and Fair in Baltimore on August 6 at 10 am which will include a visit by the “Latch on
America” Cross Country Bus Tour. The DC Breastfeeding Coalition also has several events sponsored during the week including an Expectant and New Mothers Community Baby Shower at Howard University Hospital on August 6.

The United States Breastfeeding Committee will also be in the area for their twice yearly meeting. Members from all over the country come together at these meetings to collaborate on the promotion and support of breastfeeding. The group will also
hold a Congressional Briefing on Improving the “Health of Families: How Employers and the Economy Benefit” which will be held on August 3.

Breastfeeding rates are increasing in the United States and that gives us something to celebrate, but we must keep the conversation going until all babies have the opportunity for the healthiest start in life possible.

What is oversupply?

So what exactly is oversupply and how do you know that you have the problem? As the term implies, when you have an oversupply of milk your body is producing more milk than your baby needs to consume. Because of this oversupply, your breasts feel painfully full even after your baby has had a feeding. Your breasts may leak milk constantly. When the milk lets down, it will flow so vigorously that it may appear that your baby is having difficulty keeping up with the flow. The baby may pull away coughing and sputtering several times during the feeding while milk spurts out all over the two of you. The baby may also experience an excessive amount of gas in their intestinal tract because they are getting an excess of sugary foremilk during the feeding.

What causes oversupply?

A number of factors can come into play and result in an oversupply of milk. It may be that a particular mother is just a natural overproducer of milk. In days gone by, women who were natural overproducers often hired themselves out as “wet nurses” to feed the babies of women who were not able to produce enough milk or who chose not to breastfeed. I have worked with many women who seem to have developed an oversupply because of over stimulation of the breasts through pumping. It is important to understand that a woman’s body usually produces milk in response to the amount of milk removed by her infant and the frequency of that milk removal. The system is designed so that the body can respond to an infant’s need by increased production. Use of a breast pump is an artificial way to remove milk from the breast. It is extremely helpful in situations where the baby is not able to suckle correctly or the mother has to be separated from her baby for prolonged periods of time. The over use of pumping is what can get the system out of whack.

What should I do about oversupply?

When an oversupply of milk is caused by excess pumping, the answer is to gradually decrease the amount and frequency of pumping sessions until you can discontinue all pumping sessions without feeling engorged. If you have a severe problem, you will need the advice of a Lactation Consultant to help you work through this process. If you are a natural overproducer of milk, you can usually keep the supply under control by having your baby empty just one breast at each feeding and by not offering the second breast at that feeding unless the baby is giving clear hunger cues. A natural over producer of milk will also need to be careful how often they pump their breasts for milk and the techniques they use with pumping. This is also a situation where a Lactation Consultant can help with the development of a satisfactory plan.

New mothers contact me several times a week with questions about engorgement. Some enlargement of a mother’s breasts is expected in the days immediately following delivery of her baby. As a mother’s body gears up to meet the needs of her newborn, this moderate amount of enlargement often signals that the new mother’s fuller supply of milk has “come in” and her baby will start receiving larger amounts of milk than they had received in the first few days after birth.  Problems develop if the amount of enlargement is enough to interfere with the baby’s ability to latch on and transfer milk from the mother’s breast.

Scientists do not have a clear understanding of the reasons that some women develop a degree of breast engorgement that is excessive and that interferes with breastfeeding. When this severe degree of engorgement develops, a woman’s breasts become hard and painful, and the distension of the breast tissue can cause flattening of the nipple making it very difficult for an infant to latch on to his mother’s breast and suckle correctly.  Unfortunately, this problem is likely to occur between the 3^rd to 5^th days after birth, after the mother has been discharged from the hospital. When the mother’s breasts are not emptied completely and regularly, the continuing pressure in the breast tissue can cause a decrease in milk supply. For this reason, a new mother who is experiencing the symptoms of engorgement that she is not able to relieve needs to seek the help of a certified lactation consultant or other knowledgeable health professional as soon as possible.

For reasons that are not well understood, first time mothers are more likely to develop engorgement. However, mothers who breastfeed their babies as soon as possible after the delivery of their baby and continue to feed as often as their baby is interested in feeding are less likely to develop the severe form of engorgement. It is also considered important to allow a baby to empty one breast well at a feeding, even if this means that the baby does not want to nurse on the second breast. Having the baby empty one breast well seems to provide a better signal to a mother’s body that she has one baby to feed without providing over stimulation and excess milk production.

There is very little research about treatment methods when engorgement does occur. However, the tried and true methods of applying cold packs to the mother’s breasts after a feeding and warm packs or a hot shower before the next feeding seem to provide some relief to the mother experiencing engorgement. Gentle massage and/or reverse pressure softening may also help to soften the nipple and areolar area enough to allow the baby to latch on and suckle, therefore emptying the breast. If the baby is not able to latch on, other methods of emptying the breast should be tried. Since prolonged engorgement can result in decreased overall milk supply, it is best to seek the help of a certified lactation consultant or other knowledgeable health professional in the early stages of engorgement that is not resolving.

For health professionals seeking additional information about the management of engorgement, the Academy of Breastfeeding Medicine has developed a protocol on engorgement.

The question about taking medication when breastfeeding should always be given careful consideration, there isn’t one answer that fits all breastfeeding mothers. In general, breastfeeding mothers are well advised to take as few medications as possible. A mother who is being treated for several medical conditions, as well as allergies, should carefully review the benefits and risks of taking allergy medicine with their physician and pharmacist. This is especially true if the infant is premature or very young.

Several factors are taken into consideration when a decision is being made about any medication a breastfeeding mother might need to take. The properties of a drug, that can result in transfer of more of the drug into a mother’s milk include low molecular weight, low protein binding, and high lipid solubility. If a mother has a very high concentration of a drug in her blood stream, more of the drug can end up in her milk supply. The baby’s age, maturity and total daily milk consumption as well as frequency of feedings are also important. This is the information your health care providers will be considering and fortunately, there are very good reference books available that review the information about each drug and provide guidance. Medications and Mothers Milk by Thomas W. Hale, PhD is one of the best resources for health care providers on this topic. The National Institutes of Health also has an excellent drugs and lactation database called LactMed.

To get back to allergy medications specifically, antihistamines are one of the mainstays of treatment for allergy. Fortunately, most of the newer non-sedating antihistamines can be used by breastfeeding mothers. Consult with your doctor and pharmacist for the names of specific medications that have been reviewed and approved for this use. Decongestant medications are used for the nasal stuffiness associated with allergy. They generally pass into human milk in very low concentrations so can be taken, however, there is some antidotal evidence suggesting they may hinder milk supply. Intranasal corticosteroid medications, available by prescription, may be used safely because very little gets into the mother’s bloodstream and therefore very little would pass through to the baby.

The bottom line is that breastfeeding mothers who suffer with pollen allergies can safely be treated for those allergies and continue to breastfeed.

According to Dr. Brazelton, touchpoints are predictable developmental crises during which a spurt in development is preceded by a temporary regression. The child who had already made several developmental gains may suddenly seem to regress in some areas even as they are acquiring new skills. So the child who was sleeping through the night may start waking several times again as they start to learn to crawl. This seemingly disorganized behavior in the child can cause disorganized behavior in parents as well. According to Dr. Brazelton, if the adults in a child’s life overreact to this period of regression, they may inadvertently reinforce regressive behaviors and cause a more lasting delay in development. On the other hand, if parents understand that this temporary regression is a normal and temporary part of the cycle of child development, they are less likely to overreact and progression to the next developmental level will proceed more smoothly.

As a pediatric nurse practitioner and lactation consultant, parents often tell me that their baby has lost interest in breastfeeding at around 4 months of age. When I ask why they think the baby has lost interest, they usually say that the baby no longer snuggles in for a peaceful and continuous feeding, but will feed for a few minutes and then pull off the breast and look around. The baby may then seem to want to play rather than go back to feeding. This distractibility on the part of the infant is frustrating, especially for busy parents who have many other tasks to accomplish when the feeding is finished. It is also worrying for a mother who fears that her baby is not taking enough food and this start and stop feeding pattern can lead to a decrease in the mother’s milk supply. Once parents understand that their baby is going through a normal developmental phase which involves a greater capacity to see objects around him and the intense curiosity to want to learn about new things, they usually feel less anxiety about this stage. It is then easy to understand that finding a quiet place with dimmed lights may be all that is needed to get the feedings back on track. Parents may also need to reevaluate whether they are offering food at times when their baby is giving genuine hunger cues since hunger and feeding patterns can change as the baby grows and develops in the first year of life.

An understanding of this important stage in infant development and some patience while the baby is working through it can prevent the too early weaning of a baby from the breast.

The ladies room suite

It is my opinion that a “ladies room suite” is the ideal place for a lactation room and that every floor in a building should have one. When I say a “ladies room suite” I am talking about the lactation room being an integral part of the ladies room or locker room, but separate from the toilet areas. I believe this is the best way to provide easy access to lactation rooms and maintain them in a clean manner. I say this after many years of struggling to get stand alone lactation rooms cleaned and properly cared for in a large multiple building organization. A lactation room in a ladies room suite is very handy for the women who are pumping. They can wash their hands in the sink and then use the sink for washing out their equipment when they are finished.

Having the lactation room in this location, and providing enough lactation rooms, would allow women to go and use the room whenever they need to without having to get a key from someone or be on a rigid schedule. When the lactation room is part of the ladies room area, it is usually in a safe and convenient location where there is already running water. A properly maintained ladies room sink area is probably not any more contaminated than our sinks at home. What we need when developing a lactation room is ease of access for those needing to use the room and routine cleaning and maintenance for these rooms.

The stand-alone lactation room

When a lactation room is stand alone, a lock (usually a cipher lock) is required to keep those who don’t belong in the room out, and to allow access to those who are authorized to use the room. Especially in a large organization with multiple rooms and multiple locations, it becomes a problem to maintain and stock the stand alone lactation room. Access must be controlled by someone and this requires a lot of administration and scheduling. When the lactation room is part of the “ladies room suite” it is routinely cleaned with the rest of the room and stocked very easily by housekeeping.

I realize that many are concerned about the cleanliness of a lactation room that is part of a “ladies room suite”, however in my experience, the restrooms are cleaned at least daily in a large organization and I cannot say that we are able to get a stand-alone lactation room reliably cleaned every day in the places where I have managed programs. The room/cubicle used for pumping is, of course, lockable when in use. Women feel less vulnerable in a “ladies room suite” because it is in a well traveled area and one that is generally recognized as off limits to men.

Most women are hesitant to admit that the birth of their baby has been less than a totally joyful experience. The expectation in our culture is that new mothers will be happy with the birth of their child and totally in love with their new babies. In fact, the stress and fatigue that accompany the addition of a baby to a new family can leave many new mothers feeling “blue” in those early days and some new mothers to develop a full blown postpartum depression.

In the first few days after the birth of an infant there are many physiologic changes occurring in a new mother’s body. Levels of the hormones estrogen and progesterone drop after delivery and are replaced by higher levels of prolactin and oxytocin in women who are breastfeeding. A new mother may be recovering from major surgery, if she has had a cesarean section, as well as labor and delivery. New babies need attention and feeding around the clock, so sleep deprivation is the norm. It is very common for a new mother to develop a case of the “baby blues” in the first week after delivery as she makes the many adjustments. Feelings of tearfulness, forgetfulness, restlessness, and irritability lasting for three to five days are characteristic. This period is self-limited and usually self-correcting as the body recovers from delivery and the new mother starts to feel more comfortable in her mothering role.

It is important to distinguish this short period of “baby blues” from the much more serious cases of postpartum depression that can occur any time during the first year after birth. A mother who is experiencing postpartum depression has much more serious and long lasting symptoms. By definition, symptoms of sadness, despair, emptiness, low self-esteem, inappropriate guilt, social withdrawal, pessimism, sleep disturbance and/or abnormal fatigue lasting at least two weeks are signs of depression. It has been estimated that 10-20% of new mothers may experience an episode of postpartum depression in the year following the birth of their child.

Postpartum depression is a serious illness that should not be taken lightly. If left untreated it can last for years and cause harmful effects for both the mother and her children. When a new mother takes care of her own health needs, her baby benefits as well. If you, or a friend, are showing symptoms of depression it is important to seek care from a health care professional as soon as possible. Depression is a treatable disease, and receiving treatment for depression does not mean that a mother will have to stop breastfeeding her baby. A variety of treatment approaches are available depending on the severity of the depression and the mother’s response. Some of the newer antidepressant medications can be used for treatment of depression while a mother is breastfeeding.

Additional information about management of postpartum depression is available at The Academy of Breastfeeding Medicine website www.bfmed.org under their protocols section.

The early days of breastfeeding a baby can be challenging, but once breastfeeding is established, it can be equally as challenging bringing this special relationship with your baby to a close. Ideally a mother and baby come to a mutual understanding that they are ready to move on. In reality, the pressures of modern work life often compel a mother to finish breastfeeding her baby sooner than either mother or baby would prefer. There is also the issue of discontinuing pumping, either the 2 or 3 pumping sessions a day of the working mother or the more frequent pumping sessions required when the baby is unable to learn to latch on and nurse.

The weaning process begins when the first human milk substitutes are introduced into the baby’s diet. If a two week old is given a bottle of infant formula each day, that baby has already begun the weaning process. Any time an infant is receiving something else other than his/her mother’s milk at a feeding time, if milk is not being removed from the mother’s breast, the mother’s body begins the process of reducing the milk supply or weaning.

So when should weaning occur? Although this is a very individual decision for each mother baby pair, the American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life with the addition of solid foods starting at 6 months. The World Health Organization recommends breastfeeding for at least 2 years. Unfortunately, less than 30% of infants in the United States receive any amount of breastfeeding more than six months.

When the time is right for weaning, the best approach is to make it a gradual process where the mother gives her body a chance to adjust to the decrease in milk production before dropping another feeding or pumping session. Rushing through the weaning process can lead to engorgement and blocked ducts that are painful for the mother, and can also lead to a breast infection known as mastitis.

Mothers who are working outside the home usually start the weaning process by decreasing the number of pumping sessions one at a time. Each time a pumping session is dropped; one should wait at least a week before dropping another pumping session. Once the mother feels comfortable all day with the reduced pumping schedule, another pumping session can be dropped. Depending on how old the infant is at the time the weaning process is begun, and whether the infant is taking solid foods, the infant will be given infant formula and/or solid foods to make up what would have been a breast milk feeding.

When mothers are able to let their babies wean themselves, the process is generally slower and many babies continue to nurse beyond the first year of life. When weaning an older infant the mother should look for feedings where the baby seems to be less interested and discontinue those feedings first. Remember that nursing is a great source of comfort for an infant as well as a means of obtaining nutrition. Try to continue to spend time cuddling with your infant to make up for the lost nursing time. Whenever possible, try not to begin the weaning process at a time when there are other stressful events happening in the family.

Weaning a baby is a transition for both mother and child, often the first of the many transitions they will navigate. Don’t be surprised if both you and your baby feel ambivalent during this process. At times you may take one step forward and then go back to more breastfeeding during a time of illness or unusual stress. Some mothers find it difficult to wean in spite of the fact that their infant is giving clear signs of being ready to wean. If the weaning process is not going smoothly, don’t hesitate to talk with your Lactation Consultant or other health care provider.

In an earlier blog post I discussed the use of herbal teas or supplements to increase milk supply. This time I will look at how prescription medications might play a role in the management of milk supply issues.

Substances that are taken to increase milk supply, whether they are herbal supplements or prescribed medications are known as “galactogogues”. In deciding to use either, it is first important to evaluate whether the milk supply is actually low and why it has decreased.

The most common cause of a low milk supply is insufficient emptying of the breasts. Be sure that you are feeding your baby as often as the baby asks to be fed when you are with your baby. When separated from your baby at feeding times, be sure to use a good quality breast pump to empty your breasts thoroughly at least every 3 to 4 hours. Remember the basic principle that the body makes milk in response to the amount of milk removed. A baby will ask to feed more often when they are signaling the mother’s body to produce more milk. Increasing the frequency of feedings and/or pumping sessions for a few days will usually lead to an increased milk supply.

Even breastfed babies between 4 to 6 months of age seldom ask to take more than 6 ounces of milk at a feeding. If your day care is asking for more than this amount of milk, you may need to review the feeding schedule to see if they might be misinterpreting your baby’s cues. After 6 months of age, solid foods are introduced into the diet and make up part of the baby’s caloric intake for the day.

So when should you think about asking for a prescribed galactogogue? According to the Academy of Breastfeeding Medicine, “Use of galactogogues for faltering milk supply should generally be reserved for situations after both a thorough evaluation for treatable causes (e.g., maternal hypothyroidism or medication) and increased frequency of breastfeeding or pumping or expression has not been successful.” It is important to remember that all medications have potential side effects and the possibility of developing a negative side effect must be weighed against the potential benefit of the medication. Once your health care provider has helped you rule out a treatable cause of low milk supply and your lactation consultant has assisted you in improving lactation management, a decision may be made to try a prescribed galactogogue.

In this country, the most commonly prescribed galactogogue is metoclopramide which is sold under the trade name Reglan. Raglan promotes lactation by antagonizing the release of dopamine in the central nervous system, thereby increasing prolactin levels (prolactin promotes milk production). It is also used for controlling the symptoms of esophageal reflux in both infants and adults. Reglan does not alter milk composition and it has been shown to augment milk supply in a number of scientific studies.

There are a number of side effects that mothers can experience when taking Reglan including restlessness, drowsiness, fatigue and diarrhea. Less common but more severe side effects can include sleeplessness, headache, confusion, dizziness, mental depression, or feelings of anxiety or agitation. Concern about the possible development of one of these side effects has lead most clinicians to prescribe Reglan for short periods of time. The Academy of Breastfeeding Medicine cautions that Reglan should not be used if patients have epilepsy or are on antiseizure medications, have a history of significant depression or are on antidepressant drugs, have uncontrolled hypertension, intestinal bleeding or obstruction, or have a known allergy or prior reaction to Reglan. They also state that Reglan does transfer into the milk, but research has demonstrated no side effects in the infants of mothers taking this medication.

Domperidome is another dopamine antagonist that is available outside the United States for treatment of esophageal reflux. According to the Academy of Breastfeeding Medicine its drug characteristics make it less likely to cross the maternal blood-brain barrier, resulting in less nervous system related side effects than metoclopramide. Domperidone is also less likely than metoclopramide to cross into the breast milk. Administration of domperidone results in significant increases in prolactin levels and it is the only galactogogue evaluated in a randomized controlled trial and shown to be safe and effective in increasing breast milk production. Side effects are very uncommon and include dry mouth, headache (resolved with decreased dosage), and abdominal cramps. Unfortunately, despite its safe use in many other countries, domperidome has not been approved for use in the United States by the U.S. Food and Drug Administration.

Prescribed galactogogues are available to help improve milk supply but need to be used with caution, and only on the recommendation of a health care provider who will monitor the reactions of both mother and baby. Before consideration is given to medication, all other efforts should be made to identify and resolve modifiable causes of low milk supply.

Additional information about use of prescribed galactogogues is available at The Academy of Breastfeeding Medicine website www.bfmed.org under their protocols section.

It is well known that doctor’s are now recommending exclusive breastfeeding for the first six months of an infant’s life with supplementation with infant formula when necessary. Mothers are often given little guidance on the introduction of complementary foods into their baby’s diet and how much breast milk they will continue to take as foods are added.

Human milk continues to form a very important part of an infant’s diet during the second six months of life and beyond. The World Health Organization recommends that human milk should remain the main food throughout the baby’s first year and an important food during the second year of life. Introducing healthy family foods gradually starting at about 6 months of age teaches young children healthy eating habits and helps them develop socially as family members.

When babies are ready to learn to eat solid foods they give clues to their readiness. These clues include: loss of the “tongue thrust” reflex, ability to sit up unassisted and hold the head up, and reaching for food and showing interest when the family is eating. The first foods introduced should be pureed or mashed and fed with a teaspoon, a few small teaspoons at a time. The quantity of food and number of solid food feedings is increased gradually as the child gets older. Between 6 to 9 months of age, babies will generally take 2-3 small feedings of solid foods. When introducing solid foods to your baby, give the milk feeding first and try a few teaspoon of solids about ½ hour later. A variety of healthy foods may be given. Start with foods high in iron. Iron-fortified cereal is commonly given in this country as the first food with fruits and vegetables added gradually. Most health care providers recommend giving the same food daily for about a week so that allergic reactions can be more easily identified.

The six to 12 month infant will continue to take approximately 4-6 ounces of milk 5 or 6 times daily during this time. Babies vary in their intake however, with some taking more or less than this amount. Your pediatric health care provider will continue to monitor your baby’s growth as the transition to solid food intake progresses.

As your baby gets older, gradually increase food consistency and variety adapting to your baby’s requirements and abilities. It is best to avoid nuts, grapes, raw carrots and hotdogs along with other foods that are difficult to chew and can pose a choking hazard for young children. Around 8 months of age, babies become very interested in feeding themselves and will often push away a spoonful of food even when they are hungry. The answer is to place small bits of soft foods within reach of the child and allow them to feed themselves. This is a messy but important part of the baby’s development of eating skills. The goal is for the older infant to become part of family mealtimes by the end of the first year of life.