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Today we continue with our FAQ series and and we will be talking about – Breastfeeding and Increasing your milk production…

The first show I did in this series was Episode # 138 Breastfeeding and increasing your milk production? I asked the question: Do you really need to increase your supply. I gave some thought as to the common scenarios that I see with mothers when it comes to milk production. I posed several questions:

Why would a mother need to increase her milk supply? Don’t all mothers make enough milk for their babies?
Can it be that some mothers do make enough, but think they don’t?
Can it be that some mothers do make enough, but they want to make lots more?
Can it be that some mothers don’t make enough milk for their babies?

I then talked about the moms who fall into the top two categories….. moms who do make enough, but think they don’t. And moms who do make enough but want to make lots more. Now I am going to talk about the mom who is not making enough milk for her baby.

Last week I said that I was going to put on my LC hat and walk you through 2 lactation consults. I will be talking about one mom Lucy today and another mom Sandra on next weeks show. Please note that this is a shortened version of what actually happens during a consult and as such is not as thorough as what really happens.

This is going to be real interesting for you. It will be as if you are a student of mine and are sitting right next to me as I conduct a private consult.

My goal is to give you an overview so you can begin to understand specific breastfeeding challenges and how we work with moms. Both are with moms who had low supply and yet their circumstances and outcomes were different. I have changed enough of the personal information, names and dates and ages and specific circumstances so that this will all be anonymous.

Lucy is a 37 year old woman who had her first baby 7 days ago. She had a vaginal birth which was induced at 38 weeks 5 days when it was discovered she had pre-eclampsia. After several tries to induce her labor, the pitocin seemed to finally kick in and once it did, she went from 5 cm which she had been stalled at for 4 hours to complete dilation and birth within 6 hours.

Lucy tells me that breastfeeding went really well during her 2 day hospital stay. She feels the baby was latching on well and postpartum nurses agreed. She had a day nurse and a night nurse observe her and offer her some tips. She was happy with her care and said they both spent some time with her answering basic questions about feeding frequency and how to tell when her baby was done. Her baby was 6 lbs 8 oz at birth and discharge weight was 6 lbs. even. This tells us that her baby as lost 8 oz in 2 days. Her discharge instructions as far as her breastfeeding goes was to continue as she had been and see the pediatrician within 2 days of discharge.

Lucy scheduled her lactation consult on the referral from her pediatrician whom she met with when her baby was 5 days old. Allies weight had dropped to 5 lbs. 10 oz which is well over the 4-6 oz loss we typically would like to see in the 5 days. While there could be scale differences, there could be excessive fluids during birth which baby lost during the first 5 days. I always take this into account as I am assessing the baby.

I take a look at the excellent charting the parents have done and there is a list of every single feeding, which side, how long and every single diaper for the last 5 days since coming home from the hospital. She is using disposable diapers.

Output: no stool for the last 2 days, before that there were 2-3 a day greenish in color pee diaper – every single feeding pee diaper was changed, but parents said that they did not feel much weight to it at all when they changed it and the color was a little darker the last few changes.

Feedings: baby has been feeding every 3 hours, both sides and for 15 minutes each side.

I make a mental note of this.

I already have a few areas of concern. It is not normal for a baby to not be stooling several times a day. By Day 5, your baby should be having about 3-4 yellowish colored stools every day. Their urine should be a light yellowish to clear and parents should be able to feel some weight with the disposable diaper by Day 5.

Another area of concern: Allie seems to be nursing like clockwork. Just like the books say. And yet, in real life, we find that many babies have not read the books, they can’t tell time and they are not nursing like clockwork.

I asked parents to tell me about the feedings… is Ally waking up every 3 hours. Is she consistently staying awake and feeding 15 minutes. Is she always hungry for both sides. Is she staying awake and actively sucking the whole time? Or does she need to keep stimulating her to wake up?

You see, for me, since the feeding routine seemed so routine, so regimented, I wondered if Lucy was watching the clock and waking up Ally to feed, or was she feeding Ally when when she awoke and appeared hungry? I was curious to know was she watching the clock and took Ally off the first breast so she could make sure Ally spent an equal amount of time on the second breast. I was also curious to know how Lucy recognized when Ally was actually done and full, rather then just being done because it had been 15 minutes.

Lucy was happy to report that she was following the plan given to her by the nurses in the hospital. Don’t let her sleep longer than 3 hours before waking her up and also don’t let her stay on one side any longer than 15 minutes.

This information was added to my notes as I needed to take this into consideration as I tried to figure out what was happening with breastfeeding. Could it be that Ally was not gaining well because she did not have a good latch? could it be that she was not being allowed to feed long enough per side? could it be that she was being woken up before she was hungry and therefore causing her to fall asleep when she was breastfeeding? Or does Lucy have a medical or anatomical issue that is making it hard for her to make enough milk?

I asked quite a few more questions about her health as it pertains to her breastfeeding. I determined that there was no simple or obvious reason in her health history that would cause her to have a low supply. I take the time to look and assess other factors such as babies oral cavity, overall health and the Lucy’s breast and nipple anatomy.

I like to think of this as a puzzle and to help get to the bottom of it all, means that we go through a process of elimination. I am looking into all the little nooks and crannys to see what raises my eyebrows and needs further investigating. Weighing Ally before and after the feeding is also a part of my evaluation. I hope that you are getting to see that there are many pieces to the puzzle to look at and take into consideration, rather than make a quick decision.

Now I wanted to see Lucy latch Ally onto the breast. As I watched Lucy sit up and place her breastfeeding pillow around her waste, I watched as she brought Ally to the breast and as I watched Ally try to latch on, I could EASILY see a few things I would like to change. Lucy was holding Ally in a very awkward position and once she did latch her on, she let go of her breast and Allie kind of hung on at the breast, with the breast slipping quite a bit out of Ally’s mouth. Lucy provided very little baby support at the breast and preferred to cross her legs and let Ally lay across her lap with Lucy’s body a few inches away from Ally.

Lucy had no pain with breastfeeding… at all. This is always so interesting to me as her baby was literally sucking on her nipple only and I could see her nipple sliding back and forth in babies mouth, kind of like a noodle. I do have to say that for most moms, this would be a killer and would cause quite a bit of nipple damage. Not to Lucy though.

After letting Ally get some food so she would not be too upset when we took her off, I demonstrated a different way for Lucy to hold Ally at the breast, one that enabled Ally to get more breast tissue in her mouth, the nipple further back, more support for baby and pillow support for Ally.

Ally kind of smiled and said: This feels better. She said that she use to feel some pinching, but again it did not hurt. However, with this change, she did not feel anything at all and actually wondered if her baby was just sleeping at breast. I told her to look down and she could easily see that Ally was power nursing, going at it with gusto and her mouth was opening and closing with a very wide gape and Ally said she never sees her mouth going like this.

I took this opportunity while Ally fed to explain in detail how much more comfortable it could be for her with proper latch and support and also said how much more milk baby can transfer if she is spending a majority of her time at the breast, in a good and well supported position. At this point, I suggested she take Ally on and off a few times so that she can practice latching Ally on all by herself. Once Lucy repeats this a few times, we let Ally stay and finish her feeding on this side. This gives me an opportunity to talk about signs of a good latch, nutritive sucking rhythm, how to tell if her baby is done with one side Throughout all this, the teaching continues.

Ally was weighed and she transferred a volume that exceeded average intake at this point. The specific numbers do not matter specifically as now I know quite a bit of info, which helps me to determine what her issue is and how to solve it.

This feeding session tell me that Lucy has more than enough milk for her baby. Observing latch tells me that while the milk is there for the taking, if Ally has a nipple only latch, she will be blocking enough of the milk flow that it can and has been making a difference as to how much milk she transfers.

As Lucy practiced latching baby on and off quite a few times on both sides, I explained to her in depth why it was not a good idea to time Lucy at breast. She definitely needs to offer both sides, at least for now, however, she needs to not have her feeding interrupted just because the clocks says it has been 15 minutes.

I responded to each and every myth that Lucy had been told as to why she should be timing her. Lucy did say that she was was fearful to let go of this routine but was willing to give my suggested care plan a few days.

I understood her fears and I reminded her of a few things:

1. Latch felt much better, even though it did not hurt her before.
2. She was actually quite amazed how active Lucy was at breast, not seeming to fall asleep until about 20-25 minutes on each side.

My care plan for Lucy:

1. Pay close attention and focus on getting the position and latch just right as this will be very important to milk transfer.
2. I suggested she pay close attention to Lucy’s sign that she was losing interest in 1 side, rather then follow the clock.
3. When she thought she lost interest in 1 side, to switch her to the other side.
4. If within 1 days she noticed an increase in urine output and she could now see that baby was having regular stools and they had transitioned into yellow mustardy color, to keep going another day and then touch base with me again and baby staying awake.
5. If after a full 24 hours, she noticed little change in output, lack of stools and baby still falling asleep and even with good latches, to call me and we would discuss a change in the care plan.
6. I wrote in the notes and also asked both parents if they understood the need to call if after 24 hours they did not notice much change.

You see, this consult had given me enough things for me to feel comfortable letting her go home and exclusively breastfeed her baby, for just a few days. I had given her a very short time frame to begin to see changes. 24 hours at first and then 24 hours after that. If everything was moving in the right direction, go another 2 days and on the 4th day she was going back to her pediatrician for a weight check.

If her baby had kept falling asleep at breast the first 24 hours after our consult, or pee diapers did not increase, I would have likely intervened and suggested she start to pump and bottle while we continued to work on breastfeeding.

Outcome: 1 day – emailed and said baby was power nursing for most feedings and only once fell asleep during early part of feeding. Pee diapers increased as far as feeling the weight of them. 2 small stools yellowish in color in the 24 hours since consult. Enough to keep going.

2 day: tons of wet diapers and 3 yellow stools much larger volume and lots of power nursing.

4 day weight check and baby was up 6 oz.

Assessment: Mom had plenty of milk for her baby. Position and latch and timing did not allow baby to get enough at breast.

This was a classic example of helpful a consult can be for a new mom. I have a strong feeling that if Lucy did not get help quickly, she would have presented a her pediatricians office 4 days later with even greater weight loss. At that point, she would have been instructed to begin supplementing with formula. Perhaps she would have been given info on pumping, perhaps not. This is a very common scenario which leaves moms thinking: I am not making enough milk for my baby. She lost too much. I needed to give her formula.
As each days passes with this routine, less breastmilk is made and the more reliant parents become on formula. It is not long after, that the breastfeeding is lost. Mom has lost any confidence in breastfeeding and is sad because it did not work out for her.

I hope you have found this case history educational and an eye opener. I bet there are many moms listening right now who will say: This is exactly what happened to me.
I know this because I hear this all the time in my practice. I really enjoy doing these case histories as I feel there is a lot you can learn from them. If you like me doing these case histories, please let me know.

If you have not joined our Facebook group, just go to….. Once you have joined, introduce yourself to the group and then leave a post about how you feel about this case history.

When presenting a case history, it always needs to be said: Every mother/baby pair is different than the next. What I did with Lucy may be very different than how a consult would unfold with you. There are too many variables for us to treat every mom and baby the same.

Lori J. Isenstadt, IBCLC

Lori j Isenstadt, IBCLCLori Jill Isenstadt, IBCLC is a huge breastfeeding supporter.  She has spent much  of her adult life working in the maternal health field. Once she became turned on to birth and became a childbirth educator, there was no stopping her love of working with families during their childbearing years.  Lori became a Birth doula and a Postpartum doula and soon became a lactation consultant.  She has been helping moms and babies with breastfeeding for over 25 years.  Lori founded her private practice, All About Breastfeeding where she meets with moms one on one to help solve their breastfeeding challenges.  She is an international speaker, book author and the host of the  popular itunes podcast, All About Breastfeeding, the place where the girls hang out.  You can reach Lori by email at: [email protected] or contact her via her website:  allaboutbreastfeeding.biz/contact

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