I had the pleasure of participating in this webinar with a midwife and lactation consultant, and we talked about how parents can get breastfeeding off to a great start in the hospital and beyond. Stay tuned for Part 2 later this month.
Most lactation consultants, including those working in outpatient hospital clinics, have switched exclusively to virtual modes (video and phone) as a way of protecting everyone during the COVID-19 outbreak. You may be wondering if it’s possible to get good lactation support without sitting in the same room as a lactation consultant, and the answer is definitely YES! During a video consult, I can still:
My support doesn’t end after we hang up! Following all consults, I still:
To make the most of our virtual lactation consult:
I bring my sensitive pediatric scale to all home visits, and weight checks and measurements of milk intake at the breast are helpful for assessing your baby’s well-being and feeding skills. If we meet virtually, I can’t weigh your baby, but I will ask you lots of questions to guide my assessment. Please keep track of:
If you have concerns about weight and milk intake, regular visits and weight checks with your baby’s pediatrician are recommended. Another option is to rent or purchase a baby scale, and I can guide you through checking your baby’s weight and milk intake during our session.
Some of my clients have bought this $55 scale on Amazon and found that it is adequate for regular weight checks but not sensitive enough to measure milk intake during breastfeeding. The Hatch changing pad and baby scale is also popular among my clients and is $150. I have done side-by-side weight comparisons with my pediatric scale and found it to be accurate within an ounce or two.
Payment and insurance
I am offering my virtual services at a discount since I do not spend any time driving or paying for gas or parking. As of this writing, I understand that telehealth services are being covered by most insurance carriers. I am billing Aetna and Meritain for my services as usual. If you have another insurance carrier, you may prepay for your session when you book an appointment, and I will provide you with a SuperBill to submit to insurance for any reimbursement you qualify for.
Do I really need to take a breastfeeding class? Can’t I just watch YouTube videos about latching instead?
My clients often say that breastfeeding is more difficult than giving birth. They wish someone had told them this when they were pregnant. The difficulty is not necessarily pain-related (although breastfeeding can be quite painful for some at the start), but rather the day-in and day-out intensity of nursing a baby again and again and again. And each session goes a bit differently, ranging from beautiful aha moments to tears of frustration for everyone involved.
A lot of new parents tell me that they had no idea that feeding their babies would be such an all-consuming task. During pregnancy, they were hyper-focused on the birth and made sure to take classes and do their reading. Given all of the information expectant parents receive about birth, it’s no wonder that what happens afterwards might feel like a footnote. Perhaps it’s because there’s so much emphasis on childbirth as this marathon-like experience. And as someone who’s had two babies, I don’t dispute that! However, it might be more apt to say that giving birth is a sprint (even if labor was long), and breastfeeding is the real marathon.
All that being said, I absolutely think that there is value in taking classes and reading about breastfeeding prenatally. Non-birth parents need this education, too! Yes, there are some great YouTube videos to demonstrate positioning and latch, but these videos aren’t nearly as useful without a fundamental understanding of why and how breastfeeding works. Pregnancy, Childbirth, and the Newborn by Penny Simpkin is a book that encompasses all of this information, with an extension section on breastfeeding. I also recommend The Womanly Art of Breastfeeding from La Leche League International as a wonderful guide to the first-time parents.
What should I do to prepare to my breasts and nipples for breastfeeding?
Good news: pregnancy is the best preparation for breastfeeding! Your breasts are building milk-making tissue throughout pregnancy, and you start making colostrum (early milk) by the time you’re 10-14 weeks along. Some expectant parents see this colostrum leaking out or can express it with their hands, and others don’t. Whether you leak or not is a sign of how your nipple plumbing works, not a predictor of your supply.
Some people recommend toughening up the nipples by rubbing them with a rough towel during pregnancy, and fortunately, this is not necessary. Nipple skin doesn’t develop calluses like the skin on our hands and feet. Postpartum nipple pain is often due to the tissue and muscles in our nipples being repeatedly stretched, much the same way we feel soreness when we start a new fitness routine. Cracked and bleeding nipples are the result of compression during breastfeeding, not dry skin. Adjustments to positioning usually make a big difference, as does softening engorged breasts to facilitate a deeper latch. As these issues resolve, so does the pain.
What do I need to buy to get ready for breastfeeding?
You really don’t need much! Here are my recommendations:
Rice. You read that correctly. Put two cups of uncooked rice into a large sock, tie off the end, and microwave for a minute or two. You now have a heat pack to soften your breasts before nursing.
Ice. During the early engorgement phase, about three days after giving birth, many parents find that it feels good to ice their breasts after nursing.
Olive oil, nipple cream, or lanolin, to soothe damaged nipples. I don’t have a favorite brand of nipple cream and encourage people to use whatever they have on hand. Lanolin can cause itching for some people since it is a wool byproduct. I recommend applying oils or creams when there is damage to the nipple skin, keeping in mind that addressing the cause of the damaged skin is crucial. Nine times out of ten, the nipples heal once the breasts soften and positioning is adjusted. If nipples do not heal despite these improvements, there is a possibility of an infection, and a medicated ointment may be necessary.
Nursing bras or tanks. To start, buy two or three bras/tanks that are not underwire (which can cause plugged ducts) and have some stretch to them. You won’t know what size you’ll be postpartum, and your size may change a few weeks later, anyway.
Breast pads. Not everyone leaks, but it’s nice to have a few cloth or disposable breast pads to tuck into your bra in case you do. I don’t recommend buying a huge case of breast pads before giving birth, as you may not need them. Some moms can have an allergic reaction on their skin to the disposable pads.
A firm nursing pillow, such as My Brest Friend or the Blessed Nest. Firm bed pillows and sofa throw pillows work well, too. A softer nursing pillow such as the Boppy can be problematic when the baby sinks too low to stay at the breast. You may also find that you prefer a more reclined hold and don’t need one of these pillows, so it’s fine to hold off on buying one.
A new, high-quality breast pump, which you get through your insurance. My top pick is the Spectra S1/S2, followed by the Medela Pump in Style. You may have a friend or relative giving you their previously used pump, but keep in mind that pumps wear out, and some pumps are meant for a single user due to contamination concerns.
A lot of people want to know if they should pay out of pocket for a wireless pump like the Willow or Elvie. I always recommend getting a regular pump from insurance first, as the cost is covered 100% and they are typically more effective and easier to use. You can decide later, based on your situation, if a wireless pump would be useful.
If your baby arrives before you get your pump from insurance, you can rent a pump from the hospital. Your OB or midwife may be able to write you a prescription for the pump to cover the rental cost by your insurance.
A pumping bra. Pumping is much more effective when you use your hands to massage and compress your breasts, and a pumping bra makes this more manageable. Combination nursing/pumping bras are an especially convenient option. Alternately, you can repurpose an old sports bra by cutting holes where the flanges can sit.
Finally, remember that you can send someone out to Target or click through Amazon Prime for anything else you might need. Or perhaps you have several boxes or bags of hand-me-down bottles and other supplies. It’s okay to politely accept these and then put them aside as you figure out what you really need.
My mom/sister/aunt didn’t make enough milk. Will I have the same issue?
Not necessarily. The factors that influence milk production are complex and multifarious, like a spider web. Certainly there could be genetic components at play, such as endocrine dysfunction, but so many cases of low milk supply can be traced back to simple and preventable causes. Many routine hospital practices, especially a generation or two ago, were not conducive to getting breastfeeding off to the best start. We now know that holding our babies skin-to-skin early and often is a powerful way to set up a good milk supply and get the hang of positioning. Frequent breast stimulation and milk removal (breastfeeding, pumping, hand expression) are important, too. When babies were regularly sent to hospital nurseries and only brought to their mothers every four hours for breastfeeding (and perhaps given bottles of formula at night while mom slept), it’s no wonder that there were milk supply problems. Making More Milk by Lisa Morasco and Diana West is a fabulous resource and may be very helpful to peruse while you’re pregnant.
When will my milk “come in”?
You now know that you start making milk during the first trimester of pregnancy, so it’s already there when you give birth. After three or four days, though, you start making more milk. This is a very important point! When I hear people talking about their milk “coming in,” they are usually referring to the early postpartum engorgement phase. It’s normal for breasts to get larger and feel heavy and tender during this time. Some people even have lumpy or firm areas on their breasts. This phase can be quite intense for some and barely register with others.
Engorgement is partly an increase in milk and partly inflammation. That’s why it can feel good to ice breasts after nursing. I also encourage people to continue taking anti-inflammatory medications (usually ibuprofen) as recommended by their health care providers to manage their postpartum pain as well as engorgement.
What can I do to prevent problems like cracked nipples, plugged ducts, and mastitis?
Nipple pain and damage is often the first breastfeeding challenge that many new parents encounter. If you received a lot of IV fluids during your baby’s birth, your breasts may be very full and firm, making it more difficult for your baby to latch deeply. Getting hands-on help as soon as possible has saved many a nipple from an otherwise unpleasant fate! A lactation consultant, postpartum nurse, or doula can help you with good positioning to bring your baby onto the breast as deeply as possible. They can also suggest measures to soften your breasts, such as heat, massage, or reverse pressure softening.
A deep latch is also the key to thoroughly draining your breasts, which goes a long way in keeping plugged ducts and mastitis at bay. If your breasts still feel very full after nursing your baby, you can try hand expression or pumping to get more milk out. Some people discourage new mothers from pumping in the very early days postpartum, claiming that this will lead to a milk oversupply. In my experience, it is better to get the milk out when someone is uncomfortably full, and the risk of oversupply is minimal provided someone is pumping as needed (once or twice a day) for relief.
Mastitis is a breast infection that can occur two ways: milk sits in the breasts for several hours, or bacteria enters the breast through damaged nipple skin. Therefore, if you have nipple damage, it’s best to wash your nipples at least once a day with soap and water and apply oil, nipple cream, or lanolin after each feeding. It’s also important to breastfeed or pump at least 8 times per 24 hours, especially in the first month postpartum while you are establishing your milk supply. Some new parents find that they can go one 4-5 hour stretch without breastfeeding or pumping, which often occurs around the time their babies are able to sleep a little longer at night. Others wake up very full after 3 hours and need to do something about it. I always recommend listening to your body and getting the milk out sooner rather than later. It’s good for keeping the ducts clear, and it’s good for supply!
People are sending me recipes for lactation cookies and telling me to drink lactation tea. Do those really work?
Oats, flax seeds, and brewer’s yeast are all known to have lactogenic properties. They’re also highly nutritious, so you have nothing to lose by eating those foods regardless of whether they boost your milk supply.
The effectiveness of lactation teas is a real question mark because they contain a blend of herbs and vary from brand to brand. You can brew them to different strengths, and no one seems to agree how many cups it takes to make a difference.
Frankly, I think the cookies and teas are nothing more than a marketing scheme that preys on the anxiety of new parents. If a client is trying to increase supply, I always start with a plan that emphasizes consistent and thorough breast stimulation and milk removal. If that is not enough, I share information about galactagogues in capsule or tincture form, which parents can discuss with their health care providers and consider taking if medically appropriate.
I want to start building a freezer stash of milk as soon as possible. How do I do this?
Returning to work looms largely in the minds of parents even before their babies arrive, and it’s understandable that they want to be as prepared as possible for that transition. I encourage people to spend the first month of their babies’ lives focusing on establishing breastfeeding. It takes this much time to figure out how to breastfeed comfortably and set up the milk supply, and adding in pumping sessions can be disruptive to breastfeeding and/or create more work during an already busy time.
After the first month, or whenever breastfeeding and milk supply are well in hand, a lot of parents pump first thing in the morning after nursing. Supply is often highest at this time, yielding a nice pumping output. Parents can freeze this milk in storage bags for up to 6 months or save it in the fridge for bottle-feeding within 6 days. It’s okay to freeze milk that has been in the refrigerator for a few days.
Silicone hand pumps, such as the Haakaa, make it easy to add milk to a freezer stash as well. You can combine milk from different sessions by leaving it at room temperature, or keep a container in the refrigerator and add to it. Chill fresh milk before adding it to a container with cold milk. When freezing combined milk, label with the date of the oldest milk.
Finally, it’s important to note that an Armageddon-level stockpile of breast milk is not necessary for going back to work. Most babies need 1-1.5 oz. (30-45 mL) of milk for every hour that they’re being bottle-fed, so for example, if you work an 8-hour day and have a 1-hour commute each way, you’ll leave about 10-15 oz. of milk for your baby. You really just need to be one day ahead of your baby’s milk intake, and you’ll continue pumping at work in order to replenish the supply. Many parents aim to have about 3-days’ worth of frozen milk to provide a generous cushion.
A month or two before returning to work, you may find it helpful to take a pumping and working class through your hospital, or schedule a session with a lactation consultant. This will give you general information about how to prepare yourself and your family for the transition of returning to paid employment and allow you to ask questions and strategize about your unique needs and circumstances. Most parents tell me that they find these classes and sessions very reassuring and empowering!
How can my people support me with breastfeeding?
A lot of people think that the best way to help a breastfeeding parent is to bottle-feed the baby, but that can actually create more work and cause disruptions for some families. As already stated regarding milk supply and plugged ducts, frequent milk removal is really important in the early days and weeks. Nature synced babies and their nursing parents together so nicely, with baby feeling hungry right about the time the parent needs to get the milk out. So sure, a nighttime bottle is an option, but it may require the breastfeeding parent to get up and pump while someone else feeds the baby, which often defeats the goal of giving anyone a break.
Fortunately, a family with a newborn has many other needs that friends and family can attend to. A few ideas:
Some family members are eager to bottle-feed as an opportunity to bond with the baby, and again, there are so many ways to do this!
Expectant parents, what other questions do you have about breastfeeding? Experienced parents, what do you wish you’d thought to ask while pregnant?
Most of the families that I support have babies that are two weeks old or younger. There's a lot going on: recovery from the birth, figuring out who this little person is, and of course, round-the-clock feeding. It's an intense time for everyone, and new parents want so badly to do everything right. They took the classes, read the books, bought the gear. They're feeding every 2-3 hours, tracking all of baby's meals and diapers on an app. Breastfeeding often happens in a chair with a nursing pillow using a position that a nurse or lactation consultant taught them at the hospital. If there are issues with milk supply or baby's ability to breastfeed, pumping and bottle-feeding sessions are thrown into the mix as well.
It often takes a few weeks to get feeding sorted out, and my role as a lactation consultant is to support families through this time. After an initial home visit to assess a family's needs and put together a short-term plan, I provide unlimited for two weeks as part of my service package. Parents can email, text, or call with questions and updates. I frequently do follow-up home visits to provide more hands-on help and do a weight check on baby. A lot of the families I see have multiple concerns around breastfeeding, so I encourage parents to address one or two issues at a time. I see very good results with families that get ongoing support.
I have also observed a common phenomenon: difficulty letting go of newborn breastfeeding practices. Particularly when parents have worked very hard to reach their breastfeeding goals, they can be reluctant to make changes that seemingly loosen their control around feeding. Those changes include feeding on cue, letting their baby sleep longer stretches, reducing pumping or bottle-feeding, trying new nursing positions, venturing out of the house. And it makes sense that parents would be hesitant to rock the boat, as they've probably had some very rough moments trying to feed their babies. They may know, logically, that they have the milk supply and a capable little nurser, but their past experiences give them pause. Can they really trust their bodies to make enough milk? Can they trust their babies to feed well at the breast? What does that even look like?
One amazing new mama that I recently supported told me that transitioning to exclusive breastfeeding was like jumping off a cliff. What an apt comparison! Even with the safety of the shining water below, taking the plunge is terrifying. I took this mama's hand in mine, and we jumped together.
You don't have to jump off that cliff alone! Book an appointment with me.
"Why is breastfeeding so difficult? I thought it was supposed to be natural!"
How many times have I heard this from new parents? Countless trillions, really. And yes, it's a valid question. After all, it doesn't make a lot of evolutionary sense that something so basic to the survival of our species would be so fraught with challenges.
The main source of parental distress is hiding under the assumption that breastfeeding is completely instinctual and doesn't need to be taught. It ain't true! Breastfeeding is a learned skill. Even chimps and gorillas in zoos don't know how to do it if they've never seen it before, so humans have come in and nursed their babies to show the other primates what to do.
New parents can be so hard on themselves (should have done more reading, should have taken more classes, should have known the unknowable). That's when I bring in the bike analogy. It's nothing original--I heard someone else talking about it and felt it was a message worth spreading.
There are many parallels between learning to breastfeed and learning to ride a bike. Both activities can be awkward and wobbly at first. Slow. The idea of falling (literally and figuratively) is scary. Actually falling hurts a lot. There are tears. But you get back up and keep practicing and trying. You may need some extra help as you find your balance (bike: training wheels, breastfeeding: nipple shield). Eventually, though, you will find your balance. You'll go faster. And after a while, you'll take off easily, enjoying yourself and feeling free.
So new parents, take heart. There will be bumps in the road, but you'll find your balance in time. Until then, be gentle with yourselves and reach out for support.
I'm here for you! Book an appointment.
One lactation consultant's musings about milk.