Prenatal Breastfeeding Counseling for the Woman

with Suspected Low Milk Supply

By Erin McCarter, RN, IBCLC

ErinMcCarterIn the last newsletter we reviewed how to determine whether a woman will be at-risk for breastfeeding problems by doing a prenatal breast and nipple assessment and by taking a thorough history.  To review, the following situations may have a negative effect on breastfeeding, no matter whether she had an epidural, her baby went to the NICU, or whether her baby went directly skin to skin and onto the breast.

Conditions that May Negatively Affect a Mother’s Milk Supply:

·          No breast changes prenatally
Trauma to the breasts (physically and emotionally)
Any surgery to the breasts or nipple
Any kind of hormonal imbalance
Infertility/trouble conceiving
History of irregular menstrual cycles/amenorrhea
Symptoms of hyper-androgenism, including acne, male patterned facial or back hair growth or  baldness
Breasts that lack fullness on one or more sides – may appear wide spaced or have a puffy appearing areola
Tubular shaped breasts or high mammary fold  (the base of the breast is at the 5th rib)
Breasts that are extremely asymmetrical
Low level of progesterone in pregnancy
Problems with the placenta forming poorly
Exposure to heavy pesticides during her adolescence

Education

Once a woman understands about her breast anatomy and the physiology of making milk, she will be better able to make positive decisions to protect her milk supply.  An important concept to impart to a woman is that there is a unique window within the first 2 weeks after delivery whereby we can increase the amount of prolactin receptor sites being laid down in the breasts, and therefore ensure that the milk supply later on is as robust as possible.  The more we inundate the breasts with stimulation, the more receptor sites will be laid down, and the greater the supply – even 8 months down the road.

Hand Expression

One of the best ways to remove extra milk from the breast in the first couple of days is by hand.  Every woman needs to be taught the importance of hand expression and how to do it.   Women can do this safely toward the end of the pregnancy, and even collect and store the colostrum, if they are so inclined.  Once the baby is born, she will only need about 1 teaspoon of colostrum every couple of hours for the first day.  Removing colostrum by hand expression is more effective than by breast pump for Days 1 and 2, as each drop is more easily collected when expressed right into a teaspoon.  For a good reference on how to hand express, see Dr. Jane Morton’s video at this link http://newborns.stanford.edu/Breastfeeding/HandExpression.html.  Good breastfeeding every 2-3 hours, coupled with hand expression, and a lot of skin-to-skin time will do wonders for promoting hormonal surges supporting both mothering and breastfeeding.

Breast Pumps

An effective breast pump will really be helpful when working with a woman with suspected low milk supply, and should definitely be implemented by Day 3.  Again the reason for this is to tell the mother’s body to make even more prolactin receptor sites in the breasts to increase her milk-making potential.  The best one to choose in this case is a hospital-grade double electric breast pump, such as the Medela Lactina or the Ameda Elite.  Because she may never have a full supply, and she may then choose to shorten her breastfeeding duration, a rental pump is a nice way to navigate this time.  If she is using a hand-me-down pump, it is really important to have the suction tested with a pressure gauge in a lactation consultant’s office, to ensure that it has maintained its effectiveness.  A hand-me-down pump is likely to be less effective than a really good hospital-grade rental pump.  Dr. Morton has also done research on what she is calling Hands On Pumping.  This technique encourages a woman to use her hands during pumping and even after she’s switched off the pump.  See this link to view the video on Maximizing Production while pumping. http://newborns.stanford.edu/Breastfeeding/MaxProduction.html.  As you can imagine, a woman responds better to the normal sensual feel of her own hands, rather than being a passive recipient of a milking machine.

Handouts/References

It is important that a family receive handouts that give her clear guidelines for expected number of feedings, target output (voids and bowel movements) for the baby, and waking techniques.  She should have a good understanding of how to assess milk transfer when a baby is nursing.  It is helpful for a mother to understand that all babies lose weight until her milk sets in and the volumes begin to increase.  However, if the weight dips below 10% of the birth weight, this is a clear indication that the family will need to starting a feeding plan, meaning pumping after feedings and then feeding the baby the expressed milk by an alternative feeding method to a bottle.  Also, this baby’s weight should be closely followed and plotted on a breastfeeding baby’s growth curve (WHO growth curve http://www.who.int/childgrowth/standards/chts_wfa_boys_p/en/index.html).  All weights should be done completely naked and preferably on the same scale.  As the weeks and months go on, a woman who is a risk for a low supply can feel empowered by plotting her own baby’s growth on a growth curve at home, or even renting a good scale from a medical supply company.  Another good reference is the book called The Breastfeeding Mother’s Guide to Making More Milk by Diana West and Lisa Marasco.

Galactogogues

A galactogogue (ga-lac-to-gog) is anything that increases a milk supply.  Although they can be helpful, they are not a magic cure for glandular insufficiency.  To really do the best for this family, focus should rest in the other tips delineated in this article as well as the extensively studied use of skin-to-skin contact between mother and baby.  Galactogogues can be in the form of foods, herbs or drugs.  Many of these foods and herbs have been used for hundreds and hundreds of years around the planet and vary with each culture, but there have been few studies to test for efficacy and safety.   Foods include high-fiber foods and grains such as barley, oats, brown rice and beans; calcium rich foods such as sesame, almonds, and dark green leafy vegetables; fruits such as apricots, dates, figs and cooked green papaya.  Herbal preparations can vary in effectiveness depending on the quality of the preparation.  Common herbs used to increase a mother’s milk supply are fenugreek, fennel, blessed thistle, milk thistle, nettle, goat’s rue, anise, red clover and shatvari.  The two prescription drugs that are used to increase supply are metoclopramide (Reglan) and domperidone (Motilium).  Both work to increase the prolactin levels.  Reglan can cause depression in some women, so it should not be used if the woman has a history of depression.  Domperidone does not have this side effect.

The Plan for the Family

1.       Frequent Breast Stimulation – Breastfeed every 2-2.5 hours adding in a lot of hand stimulation/expression on Days 1-2 and then switch to 10 mins of pumping (even if no milk is coming out) from Day 3 until the milk really sets in.
2.       Ensure a Good Latch & Watch for Signs of Milk Transfer.
3.       Use a feeding diary to record feedings, wet/poopy diapers, and pumped volumes of milk.
4.       Notify the Midwife if there is no clear day of breast engorgement, or if the baby has very little wet/poopy diapers, orange urine, and/or jaundice.
5.       If the weight loss is greater than 10% of the birth weight, supplementation is appropriate; feed baby mother’s expressed milk, screened donor milk, or formula (in that order of preference).
6.       Closely follow the baby’s weight, especially during times of typical growth spurts and plot on a growth curve.  The baby should stay pretty close to the same weight percentile on which it was born.
7.       Consider meeting with a Lactation Consultant prenatally or after the baby has come.

The Plan for the Midwife

1.       Discuss with the mother prenatally that she may be at risk for a low supply and what the plan will be.  Have her choose a doctor for her baby prenatally so she is prepared if there is a problem.
2.       Provide education to family on what is normal, so a family can determine if their situation is “not normal.”
3.       Carefully review how to achieve a good latch, how to assess for milk transfer, how to keep their baby awake during the feeding, and signs of jaundice and dehydration.
4.       Closely follow the baby’s weight and do a careful assessment of jaundice and dehydration especially around Days 3-5.
5.       Connect them with a lactation consultant if feeding problems arise or if supplementation is needed.

Working through this challenging time when breastfeeding expectations are needing to be modified can be an emotional time for families.  You may have a hard time imparting this information, as many women feel a true loss and are tearful.  The best way to communicate is in a loving, supportive, but also very frank way.  Even if it becomes necessary for a family to supplement 80% of their baby’s calories with a food source other than mother’s breastmilk, the baby is still getting some of her “wonder food,” the health benefits and bonding time with her baby.  There is the old adage that there is more to breastfeeding than just breastmilk, and I encourage women with glandular insufficiency to still have the suckling/cuddly time be a part of their relationship with their baby.  When a woman is prepared prenatally, provided with good anticipatory guidance, close follow-up and support she can work through her breastfeeding experience in the best possible way, while at the same time ensuring that the baby has been well looked after.  Thank you for all that you do to protect and promote breastfeeding!

Erin McCarter is an International Board Certified Lactation Consultant & Registered Nurse.  She works for Mother’s Milk & More in Boise, Idaho.  www.MothersMilkandMore.com

GOOD POSITIONING AND ALIGNMENT:  Have the mother sit up as much as possible.  Add enough pillows so that the baby’s mouth is at the height of the nipple and the mother can relax her biceps.  Roll the baby toward the mother so that they are “tummy to tummy, chest to chest, nose and chin must touch the breast.”

SKIN TO SKIN:  Babies learn better and are more stimulated during a feeding if you nurse the baby in a diaper only in direct contact with mom’s skin, rather than fully dressed, especially when the baby is learning to breastfeed.

NOSE ACROSS FROM NIPPLE:  Ensure that the baby’s neck is not bent with its chin on its chest before latching on.  Particularly with the football hold, move the baby way back so its nose is across from the nipple when the breast is in a relaxed (not pulled) position.  This is an Asymmetrical Latch.

HOLD BABY’S HEAD:  In the beginning, babies benefit by having help to achieve an excellent latch.  Holding the head behind the ears also allows control over the timing.  Hold the baby just a little away from the breast so you can see when the baby opens wide.  If the baby consistently arches away from the breast, honor that, then gently encourage another try.

SHAPE THE BREAST IN ALIGNMENT WITH MOUTH:  Would you take a bite of a big bagel sandwich if it was perpendicular to your mouth?  No matter what the nipple looks like, by “pinching” the breast into a definitive shape, the baby knows where to put his gums.  Usually the margin of the areola is a good guide for the thumb and forefinger.  Use only a “C” or “U” hold, depending whether the baby’s mouth is vertical or horizontal.  Beware that you place your fingers other than where the baby’s gums need to go!

EXPRESS COLOSTRUM:  This is a perfect time to learn to express colostrum.  The taste can tantalize a baby into rooting behavior and good suckling.

BRUSH, WAIT, AND SWING:  BRUSH the lips with the nipple to encourage the rooting reflex.  WAIT for the wide mouth, then plant the lower lip and SWING the nose around to touch the breast.  The last thing to flip into the mouth is the nipple.

DON’T LET GO:  A common mistake is to immediately let go of the “pinched” breast.  Don’t do this until you believe that the baby is committed to suckling; otherwise the breast becomes more ambiguous in the mouth.

INVESTIGATE:  We think the baby’s mouth was wide open, but we need to be certain.  Carefully push the breast in until you can see the corner of the baby’s mouth.  Both lips should be flanged and the angle of the jaw should be 140 degrees.  If it’s not that wide, fix it!  Either attempt to relatch with wide mouth as described above, or as the baby is sucking, apply counter pressure to the back of the head while pulling down on the chin.  Do this until you feel the jaw relax.  It may take several attempts.

DOUBLE-CHECK THE LATCH:  If you had to fix the latch, visually inspect the jaw angle to make sure that you’ve achieved your goal.  Also, whenever the baby takes a long pause during the feeding and starts to nurse again, double-check the latch to ensure the jaw angle is 140 degrees.  If not, fix it.

THE PERFECT LATCH:  The baby’s head is tilted slightly back with chin well in against the breast and held in firmly against the shoulders, thus keeping the baby uncurled.  The angle of the jaw is 130 to 140 degrees.

OTHER CONSIDERATIONS

Patience and time:  Learning takes time; try again later if necessary.  Baby may be sleepy the first 24 hours and not nurse well.  By the second day baby needs to nurse because his reserves are down.

Suck training:  Babies can get the suck organized by sucking on a finger for a minute or two.  Stimulate the palate as necessary.  The tongue should be cupped around the finger and should be pulling back.

Excessively sleepy or disinterested baby:  Use colostrum to invigorate the baby as needed.  Thoroughly wake the baby before latching.

Excessive tension or clamping:  Gentle jaw massage and oral assessment may be revealing.

Excessive spitting up of mucus/fluid:  Baby probably doesn’t feel like eating.

Try a different position or the other breast after making a good effort using the tips above.  Nurse for a minimum of 10 minutes per breast so that baby will get both foremilk and hindmilk.  If the baby comes off the breast after 5 minutes, put him back on the same breast.  Nursing at one breast for a long feeding is fine if using one breast per feeding.  The baby is done feeding when he is contented, satisfied, and no longer swallows with breast compression.  He should be having has lots of wet diapers and 4 to 8 bowel movements each day.  Additional water is not needed.

If no latch is achieved by 12 hours postpartum, mom should begin double pumping (both breasts at the same time for 15 minutes) every three hours.

If latch is not achieved in the first 24 hours, seek immediate assistance from your care provider.  Options are available to continue to practice breastfeeding and supplementing at the same time.

WORKING MOTHERS:  If returning to work or school, double pumping will encourage better milk production.  This means pumping both breasts simultaneously using a breast pump, such as Ameda or Medela.
Erin McCarter, RN, LE, shared these great breastfeeding helps at the IMC Summer Retreat, July 2006.

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