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​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:

• Offer reassurance, empathy, and emotional support (always important, now more than ever)
• Take a complete history
• Visually assess breasts and nipples
• Visually assess baby’s mouth and latch
• Help with positioning
• Help with pumping
• Help with bottle-feeding
• Advise on breast and nipple care
• Answer questions about feeding and general newborn behavior
• Talk with partner/support person about how they can help
• Provide a written care plan to keep baby well-fed and maximize milk supply

My support doesn’t end after we hang up! Following all consults, I still:

• Send an email summary about our session, including useful videos and information
• Share my clinical notes with your family’s health care providers (pediatrician, midwife, and/or obstetrician)
• Provide two weeks of unlimited follow-up communication by email and text

To make the most of our virtual lactation consult:

• Hold off feeding your baby for 60-90+ minutes beforehand.
• Set up yourself and your baby in a place with adequate lighting.
• If possible, have a support person available to hold your electronic device and point the camera.
• If you need help with pumping, have your pump set up nearby.
• Don’t worry about cleaning your house or looking “camera ready”!

Weight checks

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:

• Your baby’s last recorded weight, including the date
• The number of times your baby feeds each day by breast and bottle
• The general length of feedings
• Diaper changes, including color and consistency of stools

 
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:

• Helping position baby at the breast
• Supporting a parent’s arms with pillows for more comfortable breastfeeding
• Providing drinks and snacks that the breastfeeding parent can eat one-handed
• Laundry
• Dishes
• Diapers
• Meal preparation
• Grocery shopping
• Errands
• Caring for pets
• Helping parents take baby to and from pediatric appointments
• Holding baby while a parent gets a nap, eats a meal, or takes a shower
• Providing words of encouragement

I could go on, but you get the picture. If you are getting offers of help, share these ideas with your people and let them know that by doing these things, they are making it possible for you to focus on your most important job: breastfeeding.

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!

• Hold, rock, and snuggle baby
• Read to baby (It’s never too early.)
• Give baby a massage
• Give baby a bath, or take a bath with baby (get in the tub first and have a helper hand baby to you, and vice versa when the bath is over)
• Talk and sing to baby
• Walk around the house with baby

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Expectant parents, what other questions do you have about breastfeeding? Experienced parents, what do you wish you’d thought to ask while pregnant?

Looking to increase your milk supply? Want to pump more, and in less time? Breast massage and compression are your best tools. Invest in a pumping bra, or make one yourself by cutting holes in an old sports bra. The idea of going “hands-free” is very appealing so that you can text or unlock the next level of Candy Crush, but using your hands may make all the difference! Experiment with where and how you massage your breasts and see how your body responds. Some people need only a light touch to get the milk flowing, while others find that placing a fist on either side of one breast and pressing is most effective.

Depending on your anatomy and the fit of your flanges and pumping bra, it may be easier or more challenging to massage while pumping. I’ve had some clients who couldn’t massage without causing a break in suction while they pumped. They had good results massaging before pumping and then tucking heat packs into the pumping bra (such as these, or using a sock filled with dry rice).
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Wireless pumps such as the Willow and Elvie make it much more difficult to massage and compress while pumping. It can be done but again depends on the individual. Anyone who relies heavily on using their hands while pumping for a good breast draining may want to refrain from dropping a lot of money on one of these pumps. I encourage people to use the pump they can get through insurance and use these massage techniques instead.

​Need help with pumping? Book an appointment with me!

A lot of families contact me with the goal of transitioning from bottle-feeding to breastfeeding or chestfeeding. In the vast majority of cases, the families originally intended to exclusively breastfeed, and their plan was derailed by early feeding challenges. Baby may be breastfeeding some of the time but need extra milk if the family is still working on increasing milk supply, or if baby has trouble breastfeeding effectively.

Guilt, shame, and disappointment are common emotions that come up for new parents who haven't yet reached their feeding goals. One of my most important roles as a lactation consultant is to validate parents' feelings. In our competitive and impatient culture, it's easy to feel less-than when our efforts don't immediately lead to the results we seek. I invite parents to step back and recognize it will likely take some time to figure everything out. In the meantime, focusing on The Three Keeps from The Womanly Art of Breastfeeding (La Leche League International, 2010) is very helpful.

1. Keep your baby fed.
I call this Rule #1. Parents who are using bottles, formula, or donor milk often feel bad about it, and I always praise them for keeping their babies well-fed. Babies who are getting enough food are typically more alert and thus easier to feed by any method, especially breastfeeding. Families who are supplementing their babies' feedings with extra milk should be working closely with their health care providers (lactation consultant, pediatrician) and getting regular weight checks to ensure that they are feeding appropriate amounts.

2. Keep your baby close.
Babies who spend a lot of time in close physical contact with their lactating parents typically return to the breast sooner. Skin-to-skin contact is important for helping babies to orient to the breast, so I encourage families to do as much of this as they can. Babies need to return to the breast on their own terms. If the breast has become a battleground, with baby actively resisting breastfeeding, then it's time to work on creating positive associations. A great starting point is lots of snuggling without any attempts at breastfeeding. Parent and baby may enjoy a warm bath together (with parent getting into the tub first and having partner hand over baby). Sleeping together also helps, as long as the family is following safe bedsharing guidelines.

3. Keep your milk flowing.
​Some babies are part-time breastfeeders as parents work on building a full milk supply with pumping and hand expression for added breast stimulation. In other cases, the lactating parent is only pumping and hand expressing, and all feeds are given by bottle. In either case, consistent and effective milk remove is critical! I see the best results when there are at least 8 breast drainings per day. I also talk to parents about the importance of avoiding long stretches in which milk just sits in the breasts; 4 hours is about the maximum amount of time anyone should go without removing milk as they're trying to boost supply.

Babies who have difficulty latching will likely need some extra support, and this is something that I do all the time. Often a few adjustments to positioning make a big difference. There may be a physical issue that we need to address, such as a tongue tie. Some babies do well with the assistance of a nipple shield for a brief time, and this is definitely a tool that should be introduced with help from a lactation consultant.

A parting thought: babies are born to breastfeed, and this instinct stays with them for many months. I have heard of cases in which an older baby of 8 or 9 months was adopted and breastfed for the very first time! It often takes patience, persistence, and good support to get a baby back to breast, but it can absolutely be done.

​Need help getting your baby back to breast? Book an appointment.

People might be surprised to learn how much time I spend helping mothers with pumping. After all, I'm a lactation consultant, so isn't my job all about helping moms and babies with positioning and latch? Sure, we work on those things, but based on personal experience and observation, a lot of the mechanics of breastfeeding get ironed out as mom and baby get to know each other. I like to tell moms that there are no rules when it comes to positioning as long as everyone is comfortable and baby is feeding well.

Pumping is a different story. It involves a machine that operates one way, with the same assembly and basic function for all users. Not everyone responds the same way to every pump, though, and thus some tweaking is often helpful to make pumping more effective and efficient. At consults, I'm able to assess a mom and baby's unique needs and tailor my suggestions accordingly. However, there are several tips that all breast pump users should know.

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• ​Make sure that your pump is in good working order. If you inherited a pump from someone else, it may be worn out, but even a brand-new pump can be defective. I have a pressure gauge that measures the vacuum of pumps, and many stores that sell pumps will do a vacuum test for free as well.
• Regularly inspect your pump kit. I'm talking about the flanges, membranes, bottles, tubing, and other plastic bits that you assemble and attach to your pump. Anything that is chipped, cracked, or worn has the potential to negatively affect the whole system and needs to be replaced.
• Make sure you are assembling your kit correctly. Is everything screwed on straight and pushed in tightly? This makes a difference! I know a mom who discovered that her pump worked much better when she pushed the tubing flush into the pump. Another mom removed the little white membranes from her Medela Pump in Style because she thought they were part of the packaging. Turns out, they're essential for the pump to work!
• Wash your pump kit just once a day! This is music to the ears of moms who exclusively pump or work outside the home. After you pump and store your milk, put your pump kit into a gallon zippered bag and stick it in the fridge. Wash everything at the end of the day.

I had the good fortune to attend a talk at UCSF last week by Jessica Shortall, author of Work. Pump. Repeat. I highly recommend this book to anyone going back to work. Jessica includes a number of awesome pumping hacks that she's discovered over the years, and her book also addresses the emotional issues faced by working parents.

Need help with pumping? Book an appointment.

This question came up over the weekend when I was teaching a breastfeeding class at Kaiser San Francisco. A sweet dad-to-be approached me during the break and said that he was under the impression that breastfeeding wasn't really possible unless a mom had access to a pump. I talked him through some of the common uses of a breast pump:

• ​​stimulating milk supply when baby can't breastfeed or transfer milk well
• engorgement relief
• drawing out inverted nipples
• mom returning to work
• other situations of mama-baby separation
• inducing lactation or relactation
• breast milk donation

All of these scenarios made sense to the dad, and then I talked about how in many cases, pumping isn't necessary. If mom and baby are mostly together and breastfeeding is going well, there might not be a reason to ever pump. And from the standpoint of human history and worldwide resources, only a small number of humans have actually had access to breast pumps. As a species, we wouldn't have lasted this long if we'd had to rely on a machine to feed our babies! The dad nodded and started laughing. "Well, of course!" he said. "Now I feel kind of silly that I didn't think of that."

I didn't think he was silly. We live in a culture dominated by technology and commercialism. Reliance on electronics has become second nature for most of us. New parents are marketed so many new products: breastfeeding apps, seats and swings that can be programmed to bounce and make noise, baby monitors with cameras, forehead scanning thermometers, and on and on. How are we supposed to know what we really need?

A lot of people see the breast pump as a must-have, and it goes on the baby gift registry automatically. I learned this a few years ago when a dear friend was expecting her first baby. Her registry included a heavy-duty electric double pump, as well as sets of bottles, several packages of milk storage bags, extra flanges, and pump cleaning supplies. We hadn't been in touch for much of her pregnancy, so looking at her registry, I assumed she was planning to return to work. Turns out, she wasn't! But all of her mama friends had told her that she needed those items, so on to the registry list they went. She ended up pumping a few times for date nights, but most of the supplies went unused and were passed along to a mom who worked outside the home. My friend probably could have gotten by with hand expression (or using an inexpensive hand pump) and a couple of bottles.

I devote a good portion of my breastfeeding classes to talking about hand expression. There are many good videos, and I show this one by Maya Bolman. It's always fun to see the reactions of the students, many of whom didn't even know that it was possible to remove milk this way! In my private practice, I teach hand expression to every mom who doesn't already know how to do it. In many cases, skilled hand expression is as effective as a high-quality pump, and it's certainly cheaper. Perhaps this is why hand expression is still not widely trusted as a good way to remove milk; there isn't much money to be made in telling people to use their hands.

A parting thought that I share with all breastfeeding families: a breast pump is not an accurate gauge of milk supply. Many moms worry that if they don't pump out a certain amount of milk that they are not making enough. Or perhaps they have been pumping for a while and notice a decrease in their output. It may appear as though their supply as dropped. Yikes! But as my wise lactation consultant mother once said to me, "Before you doubt your body, doubt the machine." Our bodies are very well designed to make milk, and our babies are good at getting it out. Pumps, however, can vary in quality. They can wear out. They can be defective. And yet new parents continue to put their trust in electronics to help them navigate the uncertain waters of infant care and feeding. I invite them to turn that notion on its head, and trust themselves instead.

Need help with pumping? Book an appointment.