Demystifying Medically Indicated Newborn Supplementation

I’ve decided to create a resource to help explain why some babies need nutritional supplementation. Breast milk substitutes have been demonized so much in today’s society that some parents balk at supplementation even when their baby depends on it. My hope is to shed some light on the when, why, how, and with what when it comes to your supplementation options. This is in a powerpoint format. I allow this resource to be freely distributed but not sold. This is a resource for moms, and a resource to use if other lactation professionals would like to teach moms. All information is cited within and at the end of the presentation. It is using the most up to date information from The Academy of Breastfeeding Medicine.

The file is located in this drop box link.
https://www.dropbox.com/s/i3khis6qtl9sj98/supplementation.pptx?dl=0

 

The Zika Virus and Breastfeeding

By now, you may have heard that the Zika virus is running rampant is some parts of South America. There have been many confirmed cases of Zika in the southern part of the United States in several states. This virus is transmitted by mosquitoes, so an otherwise normal female mosquito that bites a person that is positive for Zika, can then continue to spread it. The WHO has a right to be concerned! For people that are not pregnant, the sickness is very mild. However, there is a strong link between the Zika virus and microcephaly. There were 4,000 cases of microcephaly in Brazil, a 2,500% increase from 2014. The earlier in pregnancy a mother is, the riskier it is to her developing baby.

What does this mean for breastfeeding mothers? Many may be concerned that they may transmit this virus to their baby. According to the CDC, there haven’t been any cases where Zika virus has been passed along through breast milk. However, the baby may still be bitten by a positively infected mosquito, and may contract the illness.

mosquito-bite

Zika virus RNA has been found in breast milk and this could actually benefit the baby. Mothers may  be passing antibodies to the Zika virus through their breast milk, which could act as a vaccine. It is unknown whether this would completely prevent the illness, or just lessen the symptoms. Currently, there is not a vaccine for the Zika virus.

The CDC has a list of symptoms to look out for, but I am unsure if these symptoms would present differently or more severely in babies and small children.

From the CDC:

  • About 1 in 5 people infected with Zika virus become ill (i.e., develop Zika).
  • The most common symptoms of Zika are fever, rash, joint pain, or conjunctivitis (red eyes). Other common symptoms include muscle pain and headache. The incubation period (the time from exposure to symptoms) for Zika virus disease is not known, but is likely to be a few days to a week.
  • The illness is usually mild with symptoms lasting for several days to a week.
  • Zika virus usually remains in the blood of an infected person for a few days but it can be found longer in some people.
  • Severe disease requiring hospitalization is uncommon.
  • Deaths are rare.

Continue to breastfeed your child, but take protective measures to prevent getting bitten by any mosquitoes. This includes eliminating potential breeding grounds for mosquitoes, making sure there is no standing water outside. Wear long sleeves and pants. Use mosquito repellent, here is an approved list for safe repellents, and limit time spent outside during high mosquito activity. Mosquitoes attack at dawn and dusk, in warm climates, and high humidity weather.

If anyone has anything to add to this post, please comment below.

Sources:

  1. http://www.cdc.gov/zika/symptoms/index.html
  2. http://www.cdc.gov/zika/hc-providers/qa-pediatrician.html
  3. http://www.cdc.gov/westnile/faq/repellent.html
  4. http://www.mosquitoworld.net/when-mosquitoes-bite/feeding-habits/
  5. http://kellymom.com/pregnancy/bf-prep/how_breastmilk_protects_newborns/

The Smart Changing Pad, Can it Replace Professional Guidance?

How would you like a product that can weigh your baby, track their growth, monitor diaper output, and tell you how much breast milk your baby consumed? When something sounds too good to be true, it usually is. The $300 price tag doesn’t help either, but you know… PROFIT.

I have to wonder if the creators collaborated with IBCLCs regarding this product. Part of me doesn’t think so. They like to prey on women that doubt their supply by claiming it can do pre and post feed weights. They also say on their website that only 5% of women deal with true low milk supply – not accurate. More like 5-15% as supported by present data. (source) However, this scale is not accurate enough to do appropriate pre and post feed weights. This scale is only accurate to 10mLs, which is a third of an ounce. The scales that lactation consultants use are accurate up to 1-2mLs, and yes, it really does matter and is important that these scales used for these purposes be that sensitive.

Cost is also a barrier here, at close to $300 you could have gotten help from a private practice IBCLC (which is usually covered by insurance). Lactation consultants have the accurate $1,000 scale, the professional advice, the follow-up, the explanation, the encouragement, the referrals, and everything else that comes from our care. What does this company want you to do? Use an inaccurate scale and get help from baby center (this is who they are associated with), a notoriously horrible information hub for baby care online. If you have concerns about your child’s growth, diaper output, or breastfeeding, see a professional, not a company. 

 

 

The Wrong Way to Raise Awareness About Public Breastfeeding

Social media. A lovely place where people run with half stories, hate, and attempts to destroy businesses in an attempt to “go viral.”

A place where people who are so starved for attention can easily find it in a 2 sentence letter that is being misread en masse. I never thought I would have to dissect a 2 sentence letter and explain it to people but it appears that I have to.

“Thank you for your letter of November 28.”

Okay, that one is simple. Let’s get to the single sentence that has caused so much trouble.

“I have addressed your concerns with the staff and we regret that you will no longer be a visitor to our Mill.”

It seems that most people on social media are reading that as if they are kicking her out of their establishment. Even I thought that at first, but then I read it again. I read this letter before I read the letter that the mother sent. I was able to gather enough information, from this one sentence, to take a wild guess that the mother stated she would not be coming back.

Then I read her letter, and that is exactly what she said.

Here’s my letter to them in which this VIRAL (!) letter was written in response: (Please share away)

28 November 2015

To Whom It May Concern:

My family and I were visiting your establishment this past week, as we do quite often. While we were chatting with Nancy who we have come to know and like over the last few years, she peered into my baby carrier and saw that I was nursing my four month old son. She told me that I needed to cover up and that last time we were there, I had (apparently) angered other customers by doing the same thing. To clarify, I was being discreet. Had she not looked directly in my carrier she would likely not even know I was nursing. In my 3+ years as a nursing mother I have never once been “called out” on nourishing my child as if I were doing something wrong. I spoke with the manager on our way out of the store and while she was nice in explaining that yes, in fact there had been some sort of situation about it in the past and that’s probably why Nancy had told me to cover myself—so as to not upset other customers, and that as a business it’s hard to maintain that level of respecting other’s wishes. Am I not a loyal customer? She assured me that that she too had breastfed her and children and ‘understood where I was coming from.’

I will tell you where I am coming from. This situation has caused me a ridiculous amount of stress and sadness. The past few days I look at my son and think, “what did we do that was wrong?” And that’s the thing. We did nothing wrong. Of course it would have been different had I fed him in the store with a bottle. A breast is a bottle is a source of nourishment for a child. There is little room for discomfort and shame to be placed on a woman who is simply meeting her child’s need, especially in a “family-friendly” business.

There are many things that upset me about this situation (and that it’s even a ‘situation’ at all) but the main thing as this is reinforcing the stigma of breastfeeding and is not helping to normalize the most natural process. To a new mother, this may humiliate and horrify her to the point it affects her decision to continue breastfeeding. I feel that is not society’s decision to make for her.

As far as my family and I returning to your business, sadly we will not. We no longer feel accepted or welcome there.

With Respect,

libel2

The mother’s response to this letter follows:

My family and I very, very regularly visited the Fly Creek Cider Mill. One of our favorite activities for sure, until a month or so ago when I was discreetly nursing my four month old son in a baby carrier only to be told to “cover up because it upsets other customers.” I sent them a letter explaining my rights as a breastfeeding mother and telling them how it made me feel—like I was doing something wrong by feeding my hungry child. This is the passive response I received from them. The lack of regard shown here speaks volumes: Fly Creek Cider Mill DOES NOT SUPPORT NURSING MOTHERS. Please feel free to share or to review their Facebook page in hopes to raise awareness that BABIES NEED TO EAT.

In this, she states that she sent them a letter explaining her rights as a breastfeeding mother. I didn’t see this anywhere in the letter that she shared as the one she sent. I hope that she sent them this;

New York’s Public Breastfeeding Law

§ 79-e. Right to breast feed. Notwithstanding any other provision of
law, a mother may breast feed her baby in any location, public or
private, where the mother is otherwise authorized to be, irrespective of
whether or not the nipple of the mother’s breast is covered during or
incidental to the breast feeding.

(Please note that a business has the right to say the mother is not allowed on the premises. If the mother chooses to stay, it then turns into trespassing.)

I’m very glad that they have addressed with their staff the mother’s concerns, however, they do not need to disclose how they addressed it. They’ve taken care of it. Hopefully if the mother sent them a copy of the breastfeeding law that would be all that they needed. Ultimately, it is her choice not to return to that business, but they aren’t going to beg her either.

Does this mean that they aren’t supportive of nursing mothers like she claims? No. Was their letter less than stellar? Yes. Should they have apologized? Absolutely.

But does it warrant a full-fledged social media attack that ultimately tanked their ratings and potentially caused them to lose business? No. And it is painfully obvious that this was not a true attempt to raise awareness about breastfeeding in public. As a lactation consultant, I’ve seen this play out many times, honest to goodness raising awareness about public breastfeeding. I’d like to say that there hasn’t been hate or anger thrown towards ignorant businesses and that everything was rainbows and butterflies and perfect apologies were given, but that wouldn’t be true. A little education goes a long way folks. It is impossible for a business to know every single law in the entire country, and it’s apparent that many businesses do not know about these laws at all. Educate them. Move on.

libel4

In my opinion, a more effective way to get one’s point across about public breastfeeding is to host a nurse in. This gets your point across without trying to ruin their business undeservingly.

Can we please remember that these businesses are a family’s livelihood? That maybe, sometimes, people depend on that income in order to survive? And also, that a little bit of ignorance about a law does not warrant an attempt to destroy them. Some of you may not think social media means much to a business, but it is a powerful thing in this day. Ratings mean a lot to a business.

After the business had been drug through the mud, here is the apology that the mother had to force from them because the first one wasn’t enough for her.

libel3

This should have been the first thing they sent her, absolutely. But we are adults, we don’t sit there and throw temper tantrums because things don’t go exactly our way. Perhaps it is time for the business to invest in a social media rep if they can afford it after this blow. But to be honest, we only have one side of this story. She can post what she said to the company all she wants, but what we have is a facebook post of something she supposedly wrote. At least we can say for sure that we have the company’s exact words to her.

No mother should ever be told to cover up while nursing her child in public. It is up to us to raise awareness about public breastfeeding without crossing lines. We must do this legally and respectfully, it is the only way to be taken seriously about issues in the adult world. This mom went about this so wrong, that this business now has everything they need to go after her for libel and loss of business. This situation is no longer an attempt to educate, its harassment in its true form.

And last but not least, the final piece in this puzzle proving that this was simply an act for attention. As if the “Let’s make this go VIRAL!” in the first post wasn’t enough of a clue.

libel1

This wasn’t an act to normalize breastfeeding, this was a selfish attack to feed off attention she knew she would get.

Feeding On Demand

Nursing on demand can be a wonderful thing. Let us remember that nursing on demand means allowing your baby to feed at the breast as many times as he wants and for as long as he wants.

I want to emphasize that this does *not* mean allowing your baby to go long periods of time without nursing.

On average, a newborn baby in the first 24 hours of life will nurse about 4 times. Most of the time these babies turn out fine, and mom can go on to have a good nursing relationship. BUT, following these guidelines to the best of your ability (what works for YOU!) is extra insurance that your nursing relationship will start off excellent. Ideally, you want to encourage your baby to eat at least 10 times in 24 hours. 

christina

The more your baby nurses;

  • the faster your milk volume will increase.
  •  the faster your baby will expel meconium which harbors bilirubin, that can increase the chance of pathologic levels of bilirubin (leading to jaundice) if not expelled. 
  • the less likely you will suffer from rock hard engorged breasts when your milk increases in volume between days 3-5.
  • the less likely your baby will be readmitted to the hospital for jaundice, hypoglycemia, dehydration, hypernatremia, or excessive weight loss.

What if my baby won’t wake up to eat?

In the first hour or two after birth is when baby will be more alert and willing to nurse. After this, it is common for them to be really sleepy for several hours. In fact, a newborn will typically sleep for about 20 hours in the first day of life. It is still important to watch for early hunger signs such as stirring in their sleep, licking their lips, and bringing their hand to their mouth. Crying is a late hunger sign. Bring your baby to breast if your baby is exhibiting these signs. Ideally, you want your baby skin to skin for as long as possible, this helps facilitate the breastfeeding experience.

What if my baby still won’t eat after watching for hunger signs?

There are quite a few options you can do to ensure your baby is being fed. According to the literature, it is not necessary to supplement a baby in the first 24 hours. These guidelines I am explaining are an ideal situation and should be a goal for establishing breastfeeding. If your baby won’t nurse you can still express your breast milk. It is most effective to do hand expression while your breasts are mainly producing colostrum. Try to do hand expression every 2-3 hours, the same you would do if your baby was nursing. You can hand express into a spoon or in a little plastic medicine cup. You can then use a dropper to feed your baby your expressed colostrum, or save it for a later time. You can also use a manual breast pump, a personal breast pump, or a hospital grade double electric breast pump. Have your IBCLC verify that the flanges fit your breasts correctly, and teach you how to assemble the pump. It is imperative that you don’t use high suction on the breast pump before your milk increases in volume. Using high suction can damage your nipples, breast tissue, cause the nipple to swell, and ultimately cause pain. A very gentle, soft suction stimulation is all that is needed. You most likely won’t get much with the breast pump. This is okay, and it’s normal. To maximize production with a breast pump, use hands-on pumping. This is when you massage and compress your breast as you’re pumping. Express your milk every 2-3 hours, until your baby is able to nurse. Colostrum is thick and syrupy, and can be difficult to express. It takes practice!


Keeping track of nursing in the beginning is helpful for everyone, but why should you worry about it? It helps let us know how nursing is going when no one is there to help you. If we see that baby is nursing frequently for a decent amount of time, and you aren’t having pain, and baby isn’t losing weight excessively, then we have more puzzle pieces to say, “Yes, nursing is going ok for you!”
However, if we see that baby isn’t nursing frequently, is having very short nursing sessions (less than 10 minutes), you’re reporting pain, baby is losing more weight than normal, or is starting to jaundice, then we have those puzzle pieces to get you the extra help that you need. Hopefully from an IBCLC!
Minimizing bumps in the road early on will help establish breastfeeding and prevent negative breastfeeding experiences for you. Nursing isn’t always easy! As an IBCLC, I made a vow to myself not to let these moms and babies fall through the cracks. We must be vigilant, listen to you, and look at the entire picture in order to be most helpful to you.
I hope you’ve found this infograph to be helpful! Let me know if you have any questions.

Edited to include: Explanation of delayed onset of milk production.

There are several risk factors for why milk takes longer to increase in volume. Risk factors include; cesarean birth, excessive IV fluids, first child, traumatic birth, long birth, hormonal issues, and anatomy issues. This list is not 100% complete as there are a lot of risk factors involved. Frequent nursing isn’t a guarantee that your milk volume will increase faster, or even in the normal time frame (3-5 days after birth). If you aren’t noticing significant breast changes by day 3 or 4, make sure you consult with an IBCLC to evaluate your specific situation. In some cases, supplementation may become necessary if milk doesn’t increase in volume between days 3-5. It is not normal for it to take longer. It may be common, but it is *not* normal, and there are specific interventions to help in these situations.

http://kellymom.com/ages/newborn/when-will-my-milk-come-in/

Feedingondemand

Circumcision Harms Breastfeeding

Before I delve into explaining why circumcision harms breastfeeding, I thought I would take the time to thoroughly define what circumcision is. Circumcision is the surgical removal of the prepuce, also known as the foreskin. The foreskin is protective tissue that covers the glans of the penis. This prevents the glans from becoming hard and keratinized as it is meant to be an internal, self-cleaning organ. It also serves several other functions, to learn more about the functions of foreskin click here. Circumcision is most often times done in the hospital, sometimes just hours after birth, or done for religious reasons on the 8th day of life. It can also be performed later in childhood for cultural reasons or as an adult for medical reasons, which is pretty rare.

“The penile foreskin is a natural and integral part of the normal male genitalia. The foreskin has a number of important protective and sexual functions. It protects the penile glans against trauma and contributes to the natural functioning of the penis during sexual activity.”

Circumcision is a painful procedure (even with anesthetic) and begins with the foreskin being grasped with forceps and the opening being forcefully stretched open. Then a metal probe is inserted into the foreskin opening which tears the foreskin away from the glans which is adhered to the glans like your nail is on your finger or toe. After that a cut it made down the middle of the foreskin with scissors. Then the foreskin is crushed, clamped (if using gomco), and cut off by a scalpel.

To see a video of a circumcision click here.

Could you imagine just being born (or even as an older baby or child) and then being subjected to this treatment? Even with anesthetic this procedure is extremely traumatic for a baby to go through. So how does this directly relate to breastfeeding? Let me explain…

There is a physiologic process that your body goes through in order to successfully begin and maintain lactation. How you manage breastfeeding can make or break your chances of meeting your breastfeeding goals. Breastfeeding already can get off to a rocky start depending on how the labor and birth went. The longer an epidural is in place the greater chance that hormones necessary to start lactogenesis stage 2 will be diluted and not function as effectively. Because epidural medication lowers blood pressure, intravenous fluids must be given to maintain blood pressure. This can cause fluid volume over load which leads to 3rd spacing. This causes your feet, legs, nipples, and other parts of your body to become swollen. This can make it really hard for baby to latch on correctly to feed, leading to nipple trauma, pain, and ineffective milk transfer. Epidural rates in America are really high, so this is already a potential “bump” in the road to a good start at breastfeeding.

Milk volume begins to increase between days 3-5 after birth. This will happen regardless if a mother chooses to nurse her baby or not. The important factor here for a breastfed baby is keeping that baby on the breast as frequently as possible. Ideally the baby should nurse 10+ times per day, and this is for multiple reasons.

  1. Babies are born with a high suck need, which serves two main functions. Recall, “My baby is using me for a pacifier!” I’m sure you’ve heard that said a lot. It’s normal. The more the baby sucks on the breast and consumes that protein rich colostrum, the faster the baby will conjugate their excess bilirubin, preventing pathologic levels of bilirubin, which, if left to accumulate turns into jaundice. Sucking causes peristalsis which helps to excrete the newborn’s meconium, which is full of bilirubin, and is a process necessary to avoid jaundice.
  2. Frequent nursing (10+ times in 24hrs) during lactogenesis stage 1 (the time period before milk increases in volume) helps to ensure a healthy long-term milk supply. Prolactin is a hormone that circulates in your body (that can be diluted by excess fluid volumes during labor) that helps stimulate milk production. Stimulation of your nipples and breasts tell prolactin to plug into prolactin receptor sites located in the breast. The more early and effective nursing that the baby does, the more this hormone will go to the right place within the breast. And this is essential for having a good long-term milk supply.

Now that you’re familiar with the physiologic process of the beginning stages of breastfeeding, and what circumcision is, I will connect the two in the following list…

  1. Circumcision requires time spent away from the mother. Usually an hour before the procedure, and 2 hours after to monitor the baby for excessive bleeding. When a newborn is not breastfeeding they should be skin to skin with mom or dad. This enhances the bond between baby and parents and helps to establish their delicate and new microbiome. It also helps milk increase in volume faster.
  2. Circumcision is a traumatic event that compromises the bond between mother and child.
  3. Some facilities require fasting before the procedure to prevent aspiration from vomiting due to severe pain. This keeps the baby from breastfeeding as much as they should be.
  4. Most baby boys that are circumcised are very hard to wake after the procedure.  Sometimes they will not eat for 6-8 hours!
  5. Urination on the raw open wound in the diaper causes extreme pain which can disrupt breastfeeding due to pain.
  6. Research has clearly demonstrated that pain adversely affects breastfeeding during the early stages.
  7. Most of the time doctors will give the baby a pacifier to cope with the pain of circumcision, and pacifiers should be avoided in the early weeks, until breastfeeding has been established.
  8. Pumping in place of the baby nursing is not as effective.
  9. Ineffective nursing can lead to decreased milk volume.
  10. The baby depends on minuscule, consistent feedings of colostrum in order to thrive in the early days. Inadequate caloric intake can cause the baby to be too sleepy to eat, which can lead weight loss of greater than 10%.

“Newborn circumcisions are a significant source of pain during the procedure and are associated with irritability and feeding disturbances during the days afterward.” – American Academy of Pediatrics

A breastfed newborn baby should be breastfeeding 10 or more times per day. This is best practice to ensure an adequate long-term milk supply and to prevent hyperbilirubinemia, hypernatremia, and hypoglycemia.

“The pain of circumcision causes breastfeeding problems in some babies. After this procedure, a baby may have trouble settling in at the breast, may refuse the breast, or may shut down and be unresponsive.”

Mohrbacher, Nancy. Breastfeeding Answers Made Simple: A Guide for Helping Mothers. Plano: Hale, 2010.

If a baby is not nursing for 6-8 hours because they are exhausted from going through the pain of circumcision…

If a baby is not stimulating the breast helping the milk to increase in volume…

If a baby is not nursing they are not causing peristalsis within their gut to get rid of meconium…

If a baby is not eating it can lead to dehydration and hypoglycemia…

Not only does circumcision harm breastfeeding, it harms the child.

Gentian Violet

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Gentian violet is a popular remedy for oral and nipple candidiasis (thrush) in the breastfeeding world. There are some things to consider about this medication in order for you to make an informed choice.

Gentian violet is derived from coal tar and is not meant to be ingested. Gentian Violet
It is carcinogenic and potentially toxic to mucus membranes which can result in ulcers in the mouth and throat. Gentian Violet Use While Breastfeeding

It is imperative that if you choose this to use to treat thrush while breastfeeding you do not use the 2% concentration, 1% has been the recommended dosage. Jack Newman has an article dedicated to the proper usage of gentian violet. Using Gentian Violet

What are some other ways to bring yeast back to normal levels?
Fluconazole medication in combination with all purpose nipple ointment.
Nystatin, although candida albicans has become resistant to this medication.
“Raw Apple Cider Vinegar diluted 50/50 with water and adding 1-2 drops of grapefruit seed oil extract. Mom then uses a qtip to paint the areas directly 3-4x/day” –Dr. Ghaheri
Avoiding excessive amounts of sugar and processed foods.
Acidophilus

These are just *some* of the ways to treat thrush. Make sure to link up with your healthcare provider and an IBCLC to see which treatment would be most effective for you!