Supplementing Solutions – How much??

I think there's a baby in the sheet??
I think there’s a baby in the sheet??

 

It’s day four of your baby’s life, and the pediatrician just told you that he’s at 14% weight loss, and that you will need to start supplementing.  It’s obvious that he needs more milk, but why?  Do you have a low supply? Did your milk come in late?  Or at all?  Or do you have plenty of milk but your baby just isn’t getting it out? What happens when you pump? Can you supplement with your own milk or do you need to use formula?  Most likely,the only one who can answer all of those questions is a lactation consultant (IBCLC), and whenever unplanned supplementing is on the menu, seeking out an IBCLC’s help should be as well. So please make an appointment to meet with a lactation consultant.

However, in the meantime, you need to feed your baby.  So, how much?

Studies have shown that breastfed babies eat about this much per feeding, at least 8 times a day:

Day One of life – 2-10 ml per feeding

Day Two of life  – 5-15 ml per feeding

Day Three of life – 1/2 oz – 1 oz (15-30 ml) per feeding

Day Four of life – 1-2 ounces (30-60ml) per feeding

Day 5 – Day 7: between 2-3 ounces (60-90ml) per feeding

Week 1- Week 2: baby will be working up to 3-4 ounces per feeding by the end of week 2. Baby will take roughly 3-4 ounces per feeding for the first 6 months of life, and then may drink a little less milk when solids are introduced.

“Well,” you say. “That’s answers the question of “how much” for the moms who are only using a bottle for a feeding. But I’m putting my baby to the breast before I give the supplement. So I would need to adjust the above numbers to what my baby needs after a breastfeed –  only, I don’t know how much he eats…which kind of puts me back to square one.”

And you’re right.  We don’t know how much your baby is taking in while on the boob. He definitely needs a supplement, but probably not the full amounts listed above (due to him probably getting some milk at the breast.) So the question of “how much to put in the bottle” is not settled yet.

At least you don't need to supplement THIS guy!
At least you don’t need to supplement THIS guy!

 

But I’ve got some good news.

If you use a paced bottle feeding method to supplement your baby, you don’t need to obsess over the measurements! 

A paced bottle feed allows your baby to regulate his intake, which means that he can tell you when he’s had enough.  (It also helps to protect your breastfeeding relationship by avoiding nipple confusion/flow preference so is a “win” all around.)

Here is how you pace a bottle feed.

  • Hold your baby upright, and brush his lips with the slow flow bottle nipple until he opens his mouth.
  • Holding the bottle horizontally so that milk just fills the nipple tip, slide the bottle into his mouth until he is latched deeply and his lips are flanged at the base of the nipple. (You might need to manually pull the baby’s lips out).
  • Allow the baby to take about 3-10 “gulps” of milk.
  • Twist the bottle nipple down and out of the baby’s mouth, and allow it to rest on his cheek. Don’t take it away or he will get mad!  Feeling the nipple resting on his cheek will let him know it’s there when he is ready.
  • Your baby will take a break to catch his breath, and if he is hungry, he will start to root for the nipple again.
  • Slide the nipple back in and continue this cycle, allowing for frequent burping breaks (every few minutes).
  • If baby is drinking the milk very quickly, you can use a pacifier a few times during the feed to help him slow down his intake. A pacifier also teaches him that he will still need to do some “work” for his food, just like when he breastfeeds.
  • When the baby stops opening his mouth and rooting for the bottle, or turns his head away, he is finished eating.  It takes about 15-20 minutes for baby’s brain to realize that his belly is full, so the bottle feeding should take about that long.
  • If the baby drinks all of the milk and still looks hungry, but less than 15 minutes have gone by, let the baby suck on a pacifier for a few minutes.  If he still looks hungry after the 15 minute mark, offer him some more milk using the same technique.

If baby shows you any signs of distress below, stop, give him a break, and allow less “gulps” before stopping him the next time.

  • Furrowed eyebrows and/or eyes opening wider and wider
  • Splayed fingers (giving you the “STOP” sign) or stiffening arms and legs
  • Milk spilling from his mouth
  • Coughing, choking, gagging, or gasping
  • Grimacing
  • Flaring nostrils which are a sign that baby is struggling to catch his breath

Here are two videos that I really like, illustrating the paced feed.

https://www.youtube.com/watch?v=TuZXD1hIW8Q

https://www.youtube.com/watch?v=1cvF1nawMNI

So let’s wrap it all up and get on with feeding your baby.

Your Supplementing Plan:

After a breastfeed, offer your baby one ounce of expressed breastmilk/formula.  Practice a paced feeding technique with your baby.  If he takes the ounce and still wants more, offer him another ounce. If he wants more after two ounces, offer him more.  Or, if he takes half an ounce and says he is done, the next time you supplement start with only 1/2 an ounce in the bottle.  Trust that your baby’s body is working and that he can communicate his hunger/satisfaction to you!*  Follow up as soon as possible with your pediatrician and/or lactation consultant to make sure your baby’s weight gain gets back on track. And know that for most moms, supplementing is a temporary measure. A good lactation consultant should be able to figure out why your baby isn’t getting enough and come up with a plan to get back to exclusive breastfeeding.

As a closing thought, I know that it can be hard to supplement when that wasn’t in your original plan. Many moms feel defeated and as though they are failing in some way when “straight from the tap” isn’t good enough anymore. However, it’s important to remember that sometimes being the “best” simply means meeting your baby’s needs, however you are able.  A baby who feels your love and has a full belly is living in a perfect little world, so take credit for that and feel good about yourself as a mom!

*Please note that if you have a pre-term baby, a small baby (under 6 pounds), or even a very sleepy baby you should be working closely with your pediatrician and an IBCLC to determine the correct amount of supplement. These babies sometimes are not trustworthy when it comes to communicating their hunger/satisfaction, and they need a focused feeding intervention.

 

Your fed, loved, and well cared for baby says, “Thanks, mom!”

 

photo credit: History of Medicine a014808 via photopin (license)photo credit: Thailand-KohSamui-TigerZoo via photopin (license)
photo credit: over the shoulder – day sixteen via photopin (license)

Safe Sex Ed Pacifier Use

pacifier1photo credit: Une tétine. / A pacifier. via photopin (license)

Have you ever heard the pitch from a sex education abstinence program? The leaders of this type of program encourage high school students to not become sexually active. “Just don’t do it -wait until you’re older/married” is the message that teens take in. And if you’re like me (the mom of a future high school student), this probably sounds like the best advice you’ve ever heard. The only problem is, this kind of teaching doesn’t work to stop kids from having sex. For many high school students, it’s just not realistic that they will choose to abstain altogether. After all, there is a monsoon of hormones swishing around, intense situations, and the urge to find some relief from pent up frustrations. Because of these factors, some teenagers will become sexually active, no matter how much we don’t want them to. And if they are having sex without being safe about it, some negative consequences might occur.  In this case, we are mainly worried about pregnancy and STDs. So if we know this to be the reality, why not teach them how to lower their risks for problems if they choose to become sexually active? And in fact, this country is starting to move away from abstinence teaching and towards contraception teaching as the national standard.  We hope to see the rate of unintended pregnancies and STDs drop as a result.

I find that pacifier teaching bears a strong resemblance to abstinence teaching.  A similar message of “just don’t do it – wait until the baby is at least one month old” is preached to new moms. And just like with abstinence education, telling a mom to avoid the pacifier initially sounds like great advice. If we can get a baby to suck only at the breast, especially during the first few days/weeks of life, we can expect an adequate milk supply and healthy weight gain.  So holding off on the binky for a few weeks is a worthy goal, with solid reasoning behind it. However, avoiding the pacifier altogether doesn’t always mesh well with the reality of living with a newborn.  And just like the teens who thought they might be able to abstain from sexual activity but got involved anyhow, many moms end up using a pacifier even if it wasn’t their original intention. (After all, there is a monsoon of hormones swishing around, intense situations, and the urge to find some relief from the pent up frustrations.) I’ve had many moms say something to the effect of, “I know it’s bad to use the binky, but it’s been helping us all to cope!” And so these moms give their babies pacifiers without any knowledge of “safe pacifier use”…. and some negative consequences might occur. In this case, the main concern is how pacifier use might interfere with establishing a milk supply.

Considering what’s at stake (a happy and healthy breastfeeding relationship) and the reality of the situation (many moms choosing to use a pacifier) I want to pose the question – is it possible to use a pacifier in the early days and limit or avoid negative outcomes?

What would happen if, like with sex ed, we shifted from a “just don’t do it” message to more of a “if you decide to use a pacifier, here is how you can help to protect breastfeeding” message? I would hope to see fewer negative consequences resulting from pacifier use. I don’t see the down side of a more forthcoming manner of teaching, as we know that many moms are using the pacifier despite the prevalent “just don’t do it” message.

 

pacifier 3photo credit: Sagan – Binky Obsession via photopin (license)

The American Academy of Pediatrics says:

“For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.”

And I would like to add that if you decide to use one anyway, please keep in mind:

Rule #1. Limit the pacifier during the first few days of life. Making milk is a simple case of supply and demand, and it is your baby’s job to tell your body to make milk. Your body is in an especially sensitive period in the hours and days after you deliver. The more you allow your baby to suck on the breast, the greater a supply of milk you will make. The less that your baby is sucking on the breast, the less milk you will make. Some babies take their job very seriously, and want to be on the boob for what feels to mom like a 24/7 shift. Moms with a baby like this may feel overwhelmed and tired of having their baby not be content unless he has a boob in his mouth. They want a break, they need a shower, they need two hands to eat their cheeseburger, and they need to put the baby down to sleep so that everyone can sleep safely. And after using the pacifier to get a little breathing room and perhaps take a nap, I would hope that a mom like this feels refreshed enough to give her baby his boob back.

So as long as your baby is feeding well 8-12 times in a day and putting out the correct amount of diapers, limited pacifier use shouldn’t be a milk-making deal breaker. You can always choose to hand express/pump a little, too, if you feel as though your body has been missing out on “make milk” signals.

Once your milk increases in volume (usually around day 3), continue to ensure 8-12 good feedings at the breast, watch for signs that baby is getting enough, and use the pacifier as desired when you really need a break but baby wants to suck.  Another good time to consider the pacifier is when you know baby wants to eat but he will have to wait a few minutes and you want to keep him calm in the meantime. For example, you’re in the shower and the baby is trying to latch on to dad, or, the baby is screaming in the carseat and your boobs just aren’t that flexible.

Rule #2. Get help if you are using a pacifier due to very sore nipples. Some moms start using the pacifier because their toes curl in pain at the mere thought of breastfeeding. A mom like this puts her baby on the breast for only as long as she can stand it and then he gets cut off. But he immediately starts crying and tries to go back on. Instead of her own nipple, the mom gives her baby his binky, which settles him and he falls asleep. Mom breathes a deep sigh of relief, but she has actually just made things worse for herself in the long run. Because the baby is sucking on the pacifier instead of her breast, her body decides to downgrade the milk supply. With less milk available, the baby will be hungry more often and will want to spend more time nursing, which is a terrible fate for a mom with sore nips.

If you are having intense nipple pain, there is something going on with the latch, baby’s suck, or both. And an IBCLC is probably the best person to help you. So, if you are using the pacifier to give your nipples a vacation, continue to use the pacifier, but definitely start pumping (and bottle feeding) to replace your baby’s demand, and get some help!

Rule #3. Don’t use the pacifier because you think your baby is eating too often. Moms in this camp look at their baby giving clear hunger cues and say “You just ate an hour ago so you’re not due to eat for at least another hour.” In goes the binky, and then maybe mom latches the baby in an hour or two. Or maybe the baby falls asleep and sleeps for 2-3 hours. Either way, this mom’s body just received a very clear signal to “make a little less” when baby would have been happy to spread the “make a little more” message. It is not possible to overfeed your baby in the first few days. Your baby has a tiny tummy and you are making small amounts of colostrum (newborn milk) which baby has to work very hard to extract. If your baby is giving clear hunger cues, put him back onto the breast, irregardless of when you fed him last. Watch your baby and not the clock. If this starts to get overwhelming, refer back to Rule#1 for some guidance and seek help from an IBCLC.

pacifier2photo credit: Baby Ben with Uncle Ben via photopin (license)

I hope that you now have a better understanding of why the “just don’t do it” message exists, and how holding off on the pacifier for a few days is typically a good move if you want to meet your breastfeeding goals.  But if you must, please practice “safe pacifier use”….and spread the word!

To wake or not to wake? That is the question.

By Michelle McKeown Poole, MS, RN, IBCLC.

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Scene I

A bedroom. The clock on the nightstand reads 3:30 a.m. Mom is awake and nervously looking at the clock. A second figure snores under the covers.

Mom: Honey. Psst. HONEY.

Partner:  Hmmmpf?

Mom: The baby’s been sleeping for three hours and seventeen minutes.

Partner: So?

Mom: So – we were told to feed him every two to three hours. Do you think we should wake him?

Partner: Are you crazy, it took forever to get him to sleep!

Mom: Ok, so let’s say that we don’t wake him.  What time will the next feed start then?  Do I wake him up in an hour? Or two hours? But if I wait two hours, it will be, let’s see…FIVE hours since he last ate!

Partner: So?

Mom: So I think that’s too long, right?

Partner: I dunno. Won’t he wake up if he’s hungry?

Mom: I don’t know! What if he doesn’t wake up – should I pump?

Partner: What? Why would you pump?

Mom: Because I don’t want my milk to dry up!

Partner: I dunno, I guess?

Mom: You guess what?!?

Partner: Pump?

Mom: Ok and then after I pump, do I wait another two hours before trying to feed again?  What if the baby wakes up right after I pump??  There will be no milk left! He’ll be so hungry! What do I do then??

Partner:  Ummm…

Baby starts crying and the parents look at each other, clearly relieved.

End scene.

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Sound familiar?

This question of waking or not waking can really get under your new parenting skin.  Your gut is telling you that a sleeping baby is a beautiful thing and why on earth would you disturb that?  But the nervous mommy part of you is freaking out looking at the clock and you imagine your milk supply dropping with every tick of the second hand.

Like many things parenting, there is no one right or wrong answer here. (Sorry.) You should decide on a plan, try it out, and if it works for you, use it!

In this case, a winning plan will be one in which your baby is gaining well AND you are ALL sleeping well.

And I think I have a winner.

Are you ready to give it a try?

(Thought so.)

I am going to assume that breastfeeding is going well for you, and that we’re talking about a healthy full term baby. (If these conditions don’t apply, consider seeing a lactation consultant to come up with a plan that is more suited to your specific needs.)

This plan involves waking the baby during the day, and letting him sleep at night.

Here’s what you’ll do:

You’re going to replace the “feed your baby every 2-3 hours” rule with the new and improved “feed your baby at least 8 times in 24 hours” rule.  Eight good feedings (15-45 minutes of active sucking and swallows) is the minimum amount most newborns need in order to gain well. Most newborns will eat more often than that (8-12 times is normal), but 8 is the minimum.

During the day, I want you to wake the baby for feeds, if he is not asking to be fed at least every 2-3 hours. When it comes to timing, I want you to watch the clock AND your baby.  Babies have a 50-60 minute sleep cycle.  This means that about once every hour, your baby is going to be in a very light sleep state. And a baby in a light sleep state is much easier to wake than a baby in a state of deep sleep.

Babies in a light sleep state will stir, you may see their eyelids flutter, or rapid eye movement as they dream. They may even make little mouth motions or suck in their sleep. When you see these signs anywhere around the 2-3 hour mark, pick your baby up, unwrap him, talk to him, change his diaper if need be and then invite him to eat. Hopefully, he will be awake enough to eat well. If you spend a good 5 minutes trying to wake him but he is not having it, stop. Wrap him up, put him back down and then try again over the next hour when you see those signs of light sleep.

So to review – while you are awake, you are feeding your baby every 2-3 hours.

At night, the plan will vary a bit based on how old your baby is.

If your baby is less than 2 weeks old: Your supply is still being established during this time, and your body is much more sensitive to the “make milk” or “don’t make milk” messages that it receives through breastfeeding (or not breastfeeding, respectively).  After about 6 hours of no milk being removed, your body will start to down regulate. And in this period where you don’t have a full supply to begin with, down regulation is a bad thing. So when you are ready to go to bed, put your baby down, put yourself down, and set your alarm for a 5 hour stretch. If your baby hasn’t woken up by the point your alarm goes off, use the gentle waking techniques above to get a feeding in.

Once your baby has hit the 2 week mark: he should be back to birth weight, which is a solid confirmation that you are doing a great job with feeding. (Yay!) It also means that you can stop setting an alarm. (Yay!) At this point, if your baby wants to sleep longer than a 6 hour stretch (and if he has you’ve won the baby lottery), let him. (Yay!) As long as he is still getting those minimum 8 solid feedings in during the rest of the day, you are good to go with the “no wake” plan.  If baby continues to sleep 6 hour + stretches on a regular basis, your milk supply will begin to downregulate during those stretches.  But this is ok, because you are now working with a full milk supply. As your baby demands more milk during his waking hours, your supply will correspondingly increase at those times to meet his needs.

And don’t worry. Your breasts are never empty. So if your baby has second thoughts about his long sleeping stretches and starts to wake during shorter intervals overnight, there will be milk there for him. It may take him a little longer to fill up, but he will.  And if he continues waking and eating at shorter intervals overnight, in a few days your breasts will be full again when he is ready to eat.

And then he’ll start sleeping through again to make you crazy. Because that’s what babies do.

So there it is, a win-win plan for success!  Give it a try over a few days/nights and see how it’s working for you. If you are getting some more sleep, and baby is getting enough to eat, it’s a keeper!

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P.S. – This plan can be a great solution for bottle feeding moms, too!

photo credits: Daily Self Portrait December 30, 2007 via photopin (license)  ,   Crying via photopin (license) ,  owen via photopin (license)

Help! I don’t think I’m making enough milk!

By Michelle McKeown Poole, MS, RN, IBCLC

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The fear of not making enough is one of the top reasons that women quit breastfeeding. The fact is, most women are making exactly the right amount of milk for their babies, and there is no reason to worry.

But I know. You’re in the hospital, trying to breastfeed your baby, and you don’t SEE or FEEL anything coming out. And in the bed next to you, the formula feeding mommy’s got a 2 ounce bottle going, and you can HEAR the baby chugging away….and it’s freaking you out!

But never fear! Your baby isn’t supposed to be drinking 2 ounces of milk on day one. When baby is born and goes to the breast, she is drinking drops of colostrum, which is the perfect amount to fill up her small belly. As your baby’s tummy quickly grows, your milk supply grows along with it. And by day ten, when your baby’s stomach is the size of a large egg and she is drinking 2-3 ounces at a time…you are making about 25 ounces of a milk every day!

“Yeah, ok,” you say, “that sounds great in theory, but how can I be SURE? What if something’s wrong and I’m not making that much?”

Here is a quick checklist to see if you are making the right amount of milk. Ask yourself:

  • Am I breastfeeding my baby at LEAST 8 times a day or as often as he is hungry?
  • Am I sure that that during feedings, my baby is actually drinking and not just sucking? (You will see a drop and pause in his chin when he takes a swallow of milk, and hear a “ka” sound.)
  • When I am finished a feeding, do my breasts feel softer and does my baby seems satisfied?
  • Is my baby making enough wet and poop diapers? (By day 5 you want to see at least 6 very wet diapers and at least 4 poops).
  • Is my baby gaining appropriate weight? (About 1 ounce gained every day for the first 4 months).

If you answered “yes” to all of these questions, relax and enjoy your breastfeeding relationship. You are making enough milk!

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And it is totally normal for a baby to nurse constantly in the afternoon/evening hours. They even have a name for this period of fussiness and cluster feeding, “the witching hour.” And trust me, you will start to feel pretty “witchy” after a few days of this!

Your breasts don’t make as much milk in the evening as in the morning, which may sound like a bad thing at first. But understand that a very full breast has thinner milk with more water and an emptier breast is making creamier thicker milk. So think of it this way – because your breasts are less full in the evening, baby is getting lots of creamy milk every time he pops on. And in theory, this calorie dense milk should help him sleep for a longer stretch afterwards. Sounding any better? Also, your baby will go through growth spurts where for a few days in a row he will up his feedings in both frequency and length. But because your milk supply is based on your baby’s demand…and as long as you are still answering “yes” to the above questions – you can feel good about the fact that your body is making just the right amount that baby is asking for every day.

If you answered “no” to any of the above questions, it is possible that your baby is not getting enough to eat. If this seems to be the situation, call your pediatrician, and then contact a lactation consultant.

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