Monday, November 19, 2012

Five things I'll kick myself if I don't tell you about breastfeeding

This is kind of a companion piece to my "first time mama's advice kit", but breastfeeding-specific. I get questions from lots of people in my life about breastfeeding, and I notice them falling over time into similar themes. I also hear after-the-fact stories of what I consider not-so-good (or terrible) advice and I kick myself, mentally, for not having somehow headed this off before it ever became an issue. So here are five things I want you to know, in no particular order:

1) Babies want to eat. They eat a lot. Let them eat. I know it can be hard. If I hear "he's just using you as a pacifier" one more time, I might scream. Do not listen to people who tell you that, or listen to them while smiling, nodding, and ignoring. Yes, some babies suck for comfort past when they are hungry. That's not bad for them. The worst thing that happens for them is that they get more food and they increase your milk supply so they have even more food available in the future. And most babies, especially very young ones, are nursing frequently! I hear "I think he's just nursing for comfort" all the time during the second-night cluster feeding period, and from moms whose milk supply is a little delayed. I try to gently explain that while they are making enough milk for their babies, it's not coming very quickly. The baby acts like he's hungry and wants to nurse because, well... he's hungry and wants to nurse: he needs to eat pretty often to get enough food.

Do you feel like you can never put your baby down and are tethered to breastfeeding 24/7? My personal opinion is that it is not the end of the world to introduce a pacifier to your baby once your milk supply is established, and you have a good read on when your baby has fed well and is satisfied. Kellymom recommends 4-6 weeks before introducing a pacifier and I tend to agree (of course there are exceptions to every rule.) Until then, try to just let feeding frequently be the norm and let go of stresses or people who guilt you about "nursing him all the time".  Trust yourself, and your baby - it is okay to feed often.

Do you feel frustrated and unsure about whether all this frequent feeding=healthy and normal or frequent feeding=starving because not enough milk? See point #2, which is...

2) Please, please, see a good lactation consultant if you have any problems. Yes - it costs money, sometimes a lot of money, and you have just spent a lot of money on, you know... having a baby. But it will be worth it. If you really, really can't afford an LC, talk to WIC to see if they have someone available, call your hospital and see what the co-pay is to see their LCs (often they will take insurance when your local private practice LCs won't), call La Leche League for referrals, and talk to the private practice people about what insurance reimbursement looks like and whether they could work out a payment plan with you. But IT IS WORTH IT to have good, hands-on help.
You might be hesitant to see an LC because "I don't know if I really have a problem". If you feel like there is a breastfeeding problem - that in itself is a problem! If the LC watches the baby nurse, checks the intake, answers your questions, and then tells you it looks like everything is okay - awesome. For example, maybe she reassures you that your baby who "eats all the time" is just a normally frequent feeder and is eating and growing beautifully. You get some ideas for coping with this and are reassured that your baby is normal and healthy.

On the other hand, if the LC finds something you can fix - now you have a way to address your issues, and you can keep working on them together if needed. You might feel like a baby who can't be removed from the breast without becoming completely frantic "shouldn't be" a problem because isn't it normal for babies to "eat all the time"? But when you go to the LC because you're completely exhausted and never sleep, you might find that the baby has difficulty transferring enough milk . Now you can work on strategies for improving the baby's milk transfer, and have a follow up visit in a few days to see if they're working.

If the person you see does not help you/listen to you/really pisses you off, find someone else. This is just like OB/midwife shopping - some people are going to be a good match, some not so much. Note: the "lactation specialist", "lactation counselor", or "lactation educator" at your pediatrician's office may be very nice, but they are not IBCLCs, and neither is your pediatrician. They may be great - they may even be better than some IBCLCs - but I have seen patients really get burned thinking they saw an LC when they didn't.

I know I sound like a broken record on the topic of seeing an LC. But sometimes it's the difference between stumbling through a dark forest with your hands outstretched, and walking through with a flashlight and a map.

3) It's not thrush. OK, OK - it's probably not thrush. But it's really, really probably not thrush. We used to think almost all chronic nipple pain was due to yeast infection of the nipples and/or the baby's mouth. A lot of IBCLCs and other health care providers are now very wedded to the idea that nipple pain without any glaringly obvious latch issues = thrush. And yet when we actually culture the nipples and yeast. Yet moms with chronic pain will go through multiple courses of antifungal treatment for "thrush", and then "resistant thrush" and then "chronic thrush". While most nipple pain is typically not thrush, if you have treated for thrush and it has not responded, it's almost definitely not thrush.

What could it actually be? Bacterial infection, vasospasm, blebs, oversupply, dermatitis, tongue or lip tie... the list goes on and on. How can you figure out which one it is? See point #2.

If you really think it might be thrush - and fine, sometimes it is! - then go ahead and treat for it. But consider the symptoms before going with that diagnosis, and don't go through multiple rounds of treatment for thrush without considering other diagnoses.

4) Measure baby's weight on the right charts. This post kind of says it all. If your pediatrician isn't using the WHO charts, you can encourage them to follow the CDC recommendations and switch to these charts for all their infants. At least bring in a copy for them to use for your baby. If you don't do this, you may start getting worried looks at some point about how "she's falling off the growth curve a little" and "maybe you should start solids early". Measure breastfed babies on breastfed baby charts!

5) Most medications are safe for breastfeeding. Most healthcare providers do not know this. I have lost count of the patients and friends who have been told by doctors, nurses, and pharmacists "you have to pump and dump while taking ____". It has been true exactly twice. I have worked with people in the intensive care unit, people who are having major health crises, multiple surgeries, etc. - and all their meds were fine. And then I meet someone who got told to pump and dump for her mastitis antibiotics! NEVER pump and dump until you have independently verified that you need to - instead, pump, label the milk with the meds you are on, and save it. Then look up your meds on Lactmed and/or call Dr. Thomas Hale's Infantrisk hotline (Mon-Fri) and discuss what you learn with your doctor/midwife/pharmacist before making the final call (nb: most health care professionals are very reassured to hear that Lactmed is run by the NIH.) Jack Newman notes that the standard warnings on the label and in the Physicians Drug Reference are about legal liability, and not about the available research and understanding of med safety. PUMP AND SAVE! And educate your health care providers, if possible, to use Lactmed and Dr. Hale's hotline and book as references, not the PDR or ePocrates.

What have I forgotten? Anyone have things to add to this list that they wish they'd known?


Kelley said...

Fantastic summary! I will reference this at our nursing group :)

Rebecca said...

Thank you, please do!

Kristal said...

I think that in your first point you said such an important thing that mothers are not told often enough or are not empowered enough to believe for themselves - trust yourself and your baby. If mothers felt confident enough to do what they felt was right for their baby and not listen to the other stuff they would be on their way to a much happier breastfeeding experience.

cdianorn said...

Do you know what else I heard A LOT from older generations? "Are you making enough milk?" AAAAGH! She was 5 weeks old and nursed every hour for an entire day and my mom insisted that I wasn't making enough milk. In her own experience, she 'didn't make enough milk' so she had to supplement with rice cereal when my brother was just 2 months old! It's hard to convince her sometimes that YES! She is getting enough milk!! (especially because she gained 4 lbs in two months.. nearly doubling her birth weight!).

Anonymous said...

Thank you for your blog. I love reading your posts as I think they contain very valuable information, and you have a lovely writing added bonus! :) I just wanted to comment on your point about pediatricians not being IBCLCs ("Note: the "lactation specialist", "lactation counselor", or "lactation educator" at your pediatrician's office may be very nice, but they are not IBCLCs, and neither is your pediatrician."). I completely agree with you that it's very important for mothers to see true lactation consultants. However, some pediatricians actually are IBCLCs, and I think it's important for mothers to know that the two are not mutually exclusive.