Sometimes breastfeeding starts and ends on Easy Street. Sometimes it kicks off in a rough patch but things smooth out over time. For babies with medical obstacles or in other unique situations, it may seem (or truly be) harder to breastfeed than to bottle-feed or formula-feed, and may be close to impossible to do.
To an individual family or mother, it may not seem (or truly be) worth the emotional or physical toll. But to a baby, it’s always worth it, and certainly deserves a try. Trying is the easy part. Succeeding is the really hard part, and it’s unfortunately it’s not guaranteed.
Technology, medicine, proper education, and increased awareness for support can help moms and babies who face special obstacles to breastfeed successfully. Have you heard about this woman breastfeeding her newborn while in a coma?? Mammary miracles do happen!
- Cleft Lip/Cleft Palate
- Down Syndrome
- Phenylketonuria in Infants (PKU)
- Premature Babies
- Tongue/Lip Tie (ankyloglossia)
- Breast Reduction Surgery
- Chronic Diseases
- Eating Disorders
- Maternal Depression Upon Let-Down (D-MER)
- Maternal Illness
- Postpartum Mood Disorders
- Sexual Abuse (Maternal)
- Teenagers Breastfeeding
- Breastfeeding in the Military
- Breastfeeding Multiples
- Breastfeeding During Pregnancy
- Cesarean Section Birth
- Same-Sex Parents
- Tandem Nursing
Good news: you can breastfeed your adopted baby even if you aren’t currently lactating or haven’t recently given birth. In fact, you can breastfeed with induced lactation even if you’ve never given birth or if you’ve already hit menopause.
How late is “too late” for a child to learn to breastfeed?
A baby’s instinct to breastfeed can remain intact even after being given an exclusive diet of formula: read this story about a woman who ended up exclusively breastfeeding her adopted premature NICU baby, “I Always Knew I Wanted to Breastfeed: My Adoptive Breastfeeding Journey.” You can nurse a child who’s out of the newborn stage (4+ months)! Read La Leche League’s “Adoptive Breastfeeding Beyond Infancy.” Here is a story of a mother whose adopted baby learned to breastfeed at a year old even after health setbacks: “Nursing Julia: My Supreme Challenge.” Also see this Karleen D Gribble, PhD, interview with LetsTalkAdoption.com about adoptive breastfeeding/breastfeeding older adopted babies.
Planning to use a surrogate or gestational carrier?
Find out how breastfeeding would work in this situation.
What is relactation?
Read my section on Relactation.
- “Breastfeeding an Adopted Older Child” – Jenny’s story
- “The Breastfeeding Chronicles: Nursing My Adopted Child” – Christina Pearson
- “The Protocols for Induced Lactation: A Guide for Maximizing Breastmilk Production” – Lenore Goldfarb and Jack Newman, MD
Alternative Feeding Methods
Can you skip the bottle and cup-feed your newborn? What about alternative feeding methods like a Supplemental Nursing System, syringe dropper, finger feeding, and others? Find out more in this post.
Breastfeeding in the Military
Many women actively work to defend more than just their own babies–they protect and serve for all the babies and families of our nation. As “Service Before Self” is a core value of the Armed Forces, women should be encouraged and applauded for their service to their family–for giving the best protection they can for their children on all fronts. You can’t get more “Made in the USA” than an American citizen’s breast milk!
Nursing mothers in active duty can turn to the Army breastfeeding support group Mom2Mom. Breastfeeding in Combat Boots: A Survival Guide to Successful Breastfeeding While Serving in the Military by Robyn Roche-Paull is another excellent resource for information and support for milkin’ military mamas. The book / The web site / The Facebook page
Be proud — breastfeed in uniform! One nation of babies, under mom, with love-by-teat and pumped milk for all (that’s how it goes, right?). Also, despite recent occasions of harassment against nursing mothers on base, nothing has changed about the policy: rest assured that you can breastfeed covered or uncovered on base, as with any other place you’re legally allowed to be.
- “Active Support for Active Duty Babes” – Robyn Roche-Paull, IBCLC, for Best for Babes Foundatio
- Bras ‘n Boots – non-profit organization dedicated to delivering care packages to female service members around the world (join the Facebook group here, or click the first link to read the blog).
- Breastfeeding Resources – U.S. Army Public Health Command
- “Mother of All Wars: The Battle to Breastfeed in Uniform” – Adam Weinstein
- Mothers at War – project includes stories, articles and blog
- “The ‘Breastfeeding-in-Uniform’ Booby Trap for Military Moms” – Robyn Roche-Paull, IBCLC, for Best for Babes Foundation
You’ve got two breasts, two nipples, and–what, you say?–two babies?? Thank god for symmetry, huh? Oh, did you say THREE (or more) mouths lusting for latch? I can almost see the wheel of hormone-induced crazy ideas spinning feverish as a hot-flash as you steal desperate glances at the baby’s father’s own set of nipples and wonder, okay when is it his turn? He’s got a pair… it could work, right?! Don’t risk your babies getting tangled in that hairy-mess chest for no reason! Trust that mama’s own two milk-makers will be just fine. Consider this your children’s very first lesson in “sharing is caring.”
- “Breastfeeding Octuplets: One Mother to Nurse 8 Babies!” – Michelle Brown
- Breastfeeding triplets around the world (Youtube video)
- Mothering Multiples (Karen Kerkhoff Gromada)
Blindness/Visual Impairment or Deafness
Are you breastfeeding in the blind? Though it probably won’t be easier than nursing as a sighted person, it certainly can’t be much harder than trying to buy, measure, mix, and feed formula without the sense of vision. One blind mother named Donna Cookson Martin who breastfed her five children is unswayed in her belief that breast is still best even when blind. Read her experience here. Also read “A Breastfeeding Story: Breastfeeding as a Blind Mother” at IANTB.
This article by Cynthia Good Mojab for LLL is aimed at those who want to help a visually impaired woman breastfeed. The bottom of the page includes direct contacts for LLL leaders who specialize in this area. For those with auditory challenges, LLL has an article aimed at Leaders: “Helping Mothers Who Are Deaf or Hard of Hearing.”
Breast Reduction Surgery
Breastfeeding success after any breast surgery of course depends on whether the ducts and nipples were traumatized and to what degree. You’ll need to talk to your surgeon about what methods were used in your operation to prepare for any future milk-making obstacles. Links:
- BFAR (Breastfeeding after Breast and Nipple Surgeries)
- “Guidelines for Breastfeeding After Breast Reduction” – Wendy Nicholson, OAM, RN, RM, LC
Breastfeeding During Pregnancy
Is breastfeeding possible while pregnant?
Yes! Read these Myths vs Facts on the topic of knocked-up nursing. Then read “What You Need to Know About Breastfeeding During Pregnancy” by Megan Rabideau, wherein she discusses common issues like nursing aversion, tender nipples, sibling bonding and more. Bronwyn Warner, ABA Counsellor, discusses what else you can expect when breastfeeding during pregnancy in this article for the Australian Breastfeeding Association.
Is breastfeeding safe while pregnant?
Not only is it safe, it’s rather common, so there’s plenty of breastfeeding mamas who you can monitor for quality assurance purposes. In various studies, babies born to mothers who breastfed during pregnancy did not show higher risk factors for health compared to those with mothers who were not breastfeeding. In the event of an especially risky pregnancy, check with a doctor first (which you’re probably already doing by double-checking that everything from your favorite perfume to your favorite TV show is A-O.K. for baby-to-be).
This article by KellyMom explains how the pregnant body is perfectly suited to nourish children of different ages without sacrificing one’s health at the expense of another, or posing a threat to the mother’s health (article also reminds about preterm labor signs). KellyMom details how the pregnant uterus is self-protecting against labor-triggering contractions from nursing (oxytocin surges):
“The specter of breastfeeding-induced preterm labor appears to spring in large part from an incomplete understanding of the interactions between nipple stimulation, oxytocin, and pregnancy…The first little-known fact is that during pregnancy less oxytocin is released in response to nipple stimulation than when a woman is not pregnant… But the key to understanding breastfeeding during pregnancy is the uterus itself. Contrary to popular belief, the uterus is not at the beck and call of oxytocin during the 38 weeks of the ‘preterm’ period. Even a high dose of synthetic oxytocin (Pitocin) is unlikely to trigger labor until a woman is at term. Many discussions of breastfeeding during pregnancy mention “oxytocin receptor sites,” the uterine cells that detect the presence of oxytocin and cause a contraction. These cells are sparse up until 38 weeks, increasing gradually after that time, and increasing 300-fold after labor has begun. The relative scarcity of oxytocin receptor sites is one of the main lines of defense for keeping the uterus quiescent throughout the entire preterm period—but it is not the only one. …In order for oxytocin receptor sites to respond strongly to oxytocin they need the help of special agents called ‘gap junction proteins’. The absence of these proteins renders the uterus ‘down-regulated,’ relatively insensitive to oxytocin even when the oxytocin receptor site density is high. And natural oxytocin-blockers, most notably progesterone, stand between oxytocin and its receptor site throughout pregnancy. With the oxytocin receptor sites (1) sparse, (2) down-regulated, and (3) blocked by progesterone and other anti-oxytocin agents, oxytocin alone cannot trigger labor. The uterus is in baby-holding mode, well protected from untimely labor.”
Why would a woman even want to breastfeed while pregnant?
Mother-led weaning is not exactly easy, and may be more trouble than it’s worth for a mother who is also dealing with a new pregnancy. Continuing to nurse an emotional older child per the usual routine may make for a smoother ride than launching into the unexpected territory of new alternatives that intend to keep a child behaviorally stable and emotionally sound, yet sometimes just confuse a child who’s not ready to accept them.
Nursing sessions offer a pregnant mother the chance to sit down, breathe, and relax for a few minutes while her child calmly and quietly nurses (to an experienced mother, “quiet” just means “tolerably still,” volume irrelevant) . She is given a respite from clearing away the legions of wooden blocks and freeze-dried strawberries that prohibit entry to all walking paths, and a moment to get cuddly-close with her big kid who no longer fits in his babywearing carrier over mom’s big belly. She can work, provide, and enjoy herself and her child, relax and take deep, uninterrupted breaths…all at once.
Some mothers are also pleased to find that breastfeeding lessens morning sickness (unfortunately, for nearly as many others it has the precise opposite effect. But let’s not harp on the bad).
Due to the drop-off in milk production that often occurs in the second trimester, or in reaction to a change in milk flavor, a number of children temporarily or permanently self-wean at this time (reminder: galactogogues are not safe to use during pregnancy). Baby-led weaning is usually easier than forcibly training the child “out” of the nursing routine, so it can be a blessing here. The decision, of course, really depends on what keeps the family collectively happiest.
“Trust yourself to make the best choice for your family” — Hilary Dervin Flower, Ma, author.
Be sure to also read my section on “Tandem Nursing” below. Back to Top
Cesarean Section Birth
Read about breastfeeding after a Cesarean birth in “Newbie Boobie Concerns.” Back to Top
See “Returning to Work.” Back to Top
Cleft Lip/Cleft Palate
A baby with cleft lip or cleft palate can breastfeed successfully, and it’s worth a motivated attempt at the very least (I will continue to repeat this for virtually every baby with almost any condition, you’ll soon notice). I emphasize this because of the miraculous situations I’ve seen with a few cleft-affected babies, and I’m a believer in the power of breastfeeding for all babies–whether medically sound, struggling to impress, or struggling to survive. Here are a few special benefits of breastfeeding a cleft-affected baby as listed by Children’s Hospitals and Clinics of Minnesota:
- “Babies with cleft lip or cleft palate tend to have more ear infections—and breast milk helps protect against these infections. The mother’s antibodies are passed on to the baby in the breast milk. For an infant facing surgery, this is a real benefit.
- “Choking and milk leaking from the nose may occur [with cleft babies]. Breast milk is less irritating to the mucous membranes than formula,because it is a natural body fluid.
- “For babies with cleft lip, breastfeeding helps strengthen the face and mouth muscles, leading to more normal facial formation. This promotes better speech skills as the baby grows.
- “The breast is more flexible than a bottle nipple, and molds itself to the shape of the lip and mouth. A breast offers a baby more control over positioning and milk flow.
- “Many infants need the extra closeness and interaction of breastfeeding. Infants suck for comfort as well as for food, and these babies may not be able to use a pacifier very well.”
- Cleft Lip and Palate Breastfeeding – resources for mothers who want to breastfeed their cleft-affected babies.
- Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate – Clinical protocol by the Academy of Breastfeeding Medicine, revised 2013
It’s been well-documented that breastfeeding leads to lower risk of chronic diseases in childhood and beyond (per observational studies that suggest a connection between prevalence of chronic diseases and “suboptimal breastfeeding”). But what happens if the mother is the one affected by chronic disease herself?
- “Fitting Breastfeeding into Your Life” by La Leche League
- “Maternal Autoimmune Disorders and Breastfeeding” by Naomi Shimamoto, BSN
- Arthritis & Fibromyalgia – This article by Katheen Kendall-Tackett, PhD, discusses the special challenges of breastfeeding with these painful and often disabling conditions, plus nursing adaptations that can help.
- Autoimmune diseases – Dr. Jack Newman says (emphasis mine):
“These illnesses are characterized by antibodies being produced by the mother against her own tissues. Some mothers have been told that because antibodies get into the milk, the mother should not breastfeed as she will cause illness in her baby. This is incredible nonsense. The antibodies that make up the vast majority of the antibodies in the milk are of the type called secretory IgA. Autoimmune diseases are not caused by secretory IgA. Even if they were, secretory IgA is not absorbed by the baby. There is no issue. Continue breastfeeding.”
- Diabetes – Find out the connection between breastfeeding and diabetes in this article by the American Diabetes Association. It’s evidenced that women who had gestational diabetes can get long-term protection from postpartum diabetes if they breastfeed for at least three months.
Pre-diabetes affects one out of every four childbearing-aged women. A new study found:
“[E]levated body mass index, elevated fasting insulin, insulin resistance and, especially, elevated fasting plasma glucose in the pre-diabetic range, were all predictors of insufficient milk supply in women attempting to exclusively breastfeed.”
AAFP on diabetes treatment compatibility:
“Insulin is not excreted into breast milk and is considered safe for use during breast-feeding. Based on studies of the distribution of first-generation sulfonylureas into breast milk, the AAP considers tolbutamide (Orinase) to be compatible with breast-feeding. Information on other diabetic agents is less complete. Glyburide (Micronase) and glipizide (Glucotrol) are highly protein-bound…therefore, they are less likely to be displaced by other drugs and unlikely to pass into breast milk. If any of the sulfonylureas are used, it is important to monitor the nursing infant for signs of hypoglycemia, such as increased fussiness or somnolence. The alpha-glucosidase inhibitors, such as acarbose (Precose), have low bioavailability, large molecular size and water solubility, so they are unlikely to be excreted into breast milk in clinically significant amounts. Because of the potential for serious side effects (e.g., lactic acidosis, hepatotoxicity) in adults, it may be advisable to avoid the use of metformin (Glucophage) and thiazolidinediones (e.g., rosiglitazone [Avandia], pioglitazone [Actos]) until more information is available on their use in breast-feeding.”
- Epilepsy – Women who receive anti-epileptic drugs are more likely to formula-feed. AAFP on treatment compatibility with breastfeeding:
“Phenytoin (Dilantin) and carbamazepine (Tegretol) are compatible with breast-feeding. Although the AAP considers valproic acid and its derivatives (valproic sodium and divalproex sodium) to be compatible with breast-feeding, some experts recommend against their use during breast-feeding because of the potential for fatal hepatotoxicity in children younger than two years. During breast-feeding, anticonvulsants other than phenobarbital and primidone (Mysoline) are preferred because the slow rate of barbiturate metabolism by the infant may cause sedation. Infant serum levels may be helpful in monitoring toxicity.”
- Herpes I & II – Herp-herp-hooray! You can* still breastfeed! The virus itself isn’t present in breast milk. So there’s the good news. The bad news is where that little asterisk comes into play: you’ll need to take special care of your condition, including a safe medicine such as Valtrex as necessary. Listen up, because this is important to know: “In young babies–a month or less–herpes can have fatal consequences. This is why mothers with active genital lesions don’t deliver vaginally. Serious complications rarely happen in babies older than 4 weeks.” (Read more about herpes and breastfeeding from LLLI).
- Hepatitis B & C – The CDC says it’s safe for a mother infected with Hepatitis B or C to breastfeed as Hepatitis is transmitted via blood, not breast milk. It recommends immunization for the baby, but does not believe it’s necessary to wait for complete immunization to begin breastfeeding. If an infected mother has cracked and bleeding nipples, it’s best to err on the side of caution and temporarily “pump and dump” while feeding the baby stored breast milk in other ways until the affected areola has healed.
- Human Immunodeficiency Virus (HIV) – It used to be that if other feeding methods were available, affordable, feasible and safe, the alternatives were recommended over breastfeeding for an HIV-infected mother. However, the newest evidence is showing that breastfeeding may still be best.
Facts from UNICEF:
- “Without preventive interventions, approximately one-third of infants born to HIV-positive mothers contract HIV through mother-to-child transmission, becoming infected during their mothers’ pregnancy, childbirth or breastfeeding.”
- “Between 15 and 25% of children born to HIV-infected mothers get infected with HIV during pregnancy or delivery, while about 15% of the children get infected through breastfeeding.”
- Factors that decrease a child’s risk of contracting the virus: exclusive breastfeeding, preventing cracked nipples, early treatment of sores/thrush, and breastfeeding for at least 3 months but not as long as the current minimum of 2 years for other women.
WHO changed its protocol in 2009, based on research showing that:
“[A] combination of exclusive breastfeeding and the use of antiretroviral treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding.”
WHO’s protocol is for the HIV-positive mother or the infants to:
“[T]ake antiretroviral drugs throughout the period of breastfeeding and until the infant is 12 months old.”
Keep in mind, exclusive breastfeeding (no other solids or liquids) is key here:
“Prior research had shown that exclusive breastfeeding in the first six months of an infant’s life was associated with a three- to fourfold decreased risk of HIV transmission compared to infants who were breastfed and also received other milks or foods.”
LLLI makes another point for affected women in developing countries:
“The social costs of not breastfeeding also must be considered. When a woman gives breast milk substitutes in a culture where breastfeeding is traditional, her community may suspect that she is HIV-positive, potentially putting her at risk for physical abuse, ostracism, and abandonment. In most parts of the world women do not know their HIV status, therefore ongoing support of exclusive breastfeeding is most appropriate and much needed.”
The CDC, on the other hand does NOT recommend that a baby with an HIV-positive mother should breastfeed. The AAP says that the pros and cons should be weighed for women in developing nations, but does NOT recommend breastfeeding for women in industrialized nations. Currently, the research into HIV infections and the antiretroviral drug effects on breastfed children is largely inconclusive, thus warranting the careful consideration of individual cases.
- Hyperthyroidism – June Isis Evasco shares her inspiring story of determining to breastfeed with Diffuse Toxic Goiter. Among many other benefits to her and the baby, she even found that breastfeeding alleviated her medication’s side effects.
- Lyme disease – Kellymom has found that no babies have developed lyme disease from breastfeeding.
This section is still undergoing changes, so check back soon for more information. If you could use extra help or insight before then, I have it — so don’t hesitate to reach out to me through the contact page.
Why do women donate their surplus milk? Many women get more milk from a pump than their child could ever need (find out who holds the Guinness World Record for “Most Donated Breast Milk”), and donations are in constant demand for premature babies and those with mothers in medically precarious positions. It’s a wonderful gift for an older baby who might otherwise be forced to have formula supplements that she cannot tolerate, for adoptive parents like same-sex couples who cannot produce their own breast milk, for single fathers, or as I’ve seen several times, bestowed by a mother as a way to grieve the tragedy of infant loss. Milk donations can also hold a gold mine of clues in breast cancer research.
Breast milk donations help babies like Charlotte, Levi John, the ones in these success stories, preemies with the highly morbid condition called nectrotizing enterocolitis (see the “Premature Babies” section) and this meth-addicted baby. Breast milk donation helped breast cancer victim Jamie Thomas and THESE TWO MAMAS who received some of my own surplus milk. Breast milk very likely would have saved Micah.
You can make a one-time donation, several donations, or become a long-term donor. If you’re interested in donating your milk surplus, you have several options. You might consider HMBANA milk banks, which provide milk to NICUs. There is also informal mother-to-mother milk donation, as linked below:
- Frequently Asked Questions here from HMBANA.
For an investigative look into milk donation, watch the 2012 documentary “Donor Milk” (purchase the DVD here) or watch the clip on the Media Brew page.
The International Breast Milk Project / The National Milk Bank / The University of Minnesota Medical Center / Milkbanking.net / The Family Birth Center / The Mother’s Touch / The Birth Connection Milk Bank / The Whole Woman, Inc. / South Coast Milk Bank / Milkin’ Mamas / Miami Maternity Center
- “Biomedical Ethics and Peer-to-Peer Milk Sharing” – Karleen D. Gribble, BRurSc, Ph.D.
- “FAST FACTS: Miracle Milk” – Best for Babes Foundation
- “Peer-to-Peer Milk Donors’ and Recipients’ Experiences and Perceptions of Donor Milk Banks” – Karleen D. Gribble
- “Milk sharing and formula feeding: Infant feeding risks in comparative perspective” – Karleen D. Gribble and Bernice L. Hausman
- “Milk sharing: from private practice to public pursuit” – James E Akre, Karleen D Gribble and Maureen Minchin
- “Think donor milk is expensive? Wait ’til you see the alternative” – Tanya Lieberman, IBCLC
International Milk Bank Links:
- Adresse des lactariums et banques de lait en France – contact info for French milk banks, or “lactariums”
- BC Women’s Milk Bank – Canada
- “Información sobre el banco de leche materna en España” – Spain’s milk bank
- “iThemba Lethu breast milk bank” – UNICEF South Africa
- Sperrin Lakeland Milk Bank – Ireland’s only human milk bank
Babies with congenital disease such as Down’s Syndrome reap irreplaceable benefits from breastfeeding. Regular physical contact, opportunities for IQ-building nutrition (even an extra IQ point or two makes a drastic difference to a child with Down Syndrome), and reinforced, affectionate human socialization is offered simultaneously and constantly with breastfeeding.
Parents of babies with this condition can also enjoy great rewards (read about what that’s like here). Breastfeeding and peaceful parenting advocate Dr. William Sears has a child with Down’s. He touches upon his experience at this location on his web site. Other advocacy figures who have Down’s affected, breastfed children include Katherine Dettwyler (“The Issue of Informed Consent“) and Becky Saenz (“Primary Care of Infants and Young Children with Down Syndrome“).
- “Breastfeeding Babies with Special Needs” – La Leche League International
- “Nobody Smiles Like I Do” – Dee Cole
- “Special Advantages of Nursing Your Baby with Down Syndrome” – Becky Flora, BSed, IBCLC
- “Welcoming Babies with Down Syndrome” – Pam Wilson
- The Baby Book: Everything You Need to Know About Your Baby – From Birth to Age Two – William and Martha Sears (pp. 181-182 and pp. 395-400)
- The Breastfeeding Answer Book (revised ed.) – Mohrbacker and Stock. (pp. 304-08)
- The Breastfeeding Book – William and Martha Sears. (pp. 213-214)
- Nursing Your Baby with Down Syndrome – Sarah Coulter Danner, CPNP, CNM, and the late Edward R. Cerutti, MD
- The Womanly Art of Breastfeeding (sixth ed.) – La Leche League International. (pp. 290-291)
Visit the “Pumping & Working Buzz” page.
Babies with galactosemia cannot entirely break down the simple sugar galactose in dairy including all milks (human, other mammal, or formula), therefore they require a specific lactose-free type of nutrition. There are three types of galactosemia that range in level of severity.
This is an extremely rare inherited disorder. About 1 in 60,000 caucasian newborns are affected (rate differs among races). Prenatal genetic testing can screen for the autosomal recessive gene that would indicate increased risk factor for galactosemia. It’s typically detected by the newborn screening test given in the first few days after birth.
- “Galactosemia” – Genetics Home Reference
Newborn jaundice is normal in most cases, appearing within 2-3 days post-birth, and affecting up to 60% of full-term babies. Physiologic jaundice is caused by a buildup of bilirubin, which is produced when red blood cells are broken down. The liver is responsible for eliminating the bilirubin, but a newborn’s liver is often too immature to efficiently handle this process yet. This causes a yellow cast on the skin (which can be trickier to detect in dark-skinned babies) and the eyeballs. This resolves itself in a week or two as the baby matures further and red blood cell levels have lowered.
In a breastfed baby, jaundice is more common and tends to persist longer than a formula-fed baby (as breastfed babies are the standard, this means it’s the norm). True breastmilk jaundice, which only affects 0.5% to 2.4% of newborns, sticks around longer than one or two weeks, sometimes up to twelve (now, this shouldn’t be confused with breastfeeding jaundice, which is caused by starvation/lack of proper milk intake). Bilirubin levels might even increase at the two-week mark. None of this is a cause for concern in an otherwise healthy baby. On how breastmilk and formula compare in causality of newborn jaundice, Dr. Sears says:
“The difference is thought to be due to an as-yet unidentified factor in breastmilk that promotes increased intestinal absorption of bilirubin, so that it goes back into the bloodstream rather than moving on to the liver. Higher rates of jaundice in breastfed infants may also be related to lower milk intakes in the first days after birth, because of infrequent or inefficient feeding.”
Hence, why medical treatments should be avoided unless truly necessary because they threaten to interrupt breastfeeding further. As breastmilk helps move the baby’s bowels to remove excess bilirubin, frequent feedings will hasten the normal bodily process. If bilirubin levels have reached more than 20 milligrams, a health provider might recommend treatment with phototherapy (ask about fiber optic blankets, an especially good option for nursing moms). What not to do: do not supplement with sugar water, and do not restrict the baby from breastfeeding.
- “Breastfeeding and Jaundice” – Jack Newman, MD, FRCPC, International Breastfeeding Centre
- “Babies with Jaundice” – Dr. Sears
- “Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation” – The Academy of Breastfeeding Medicine Protocol Committee
Maternal Depression Upon Let-Down (D-MER)
D-MER is a physiological response to nursing caused by shifts in hormone levels, specifically dopamine at the beginning of a feeding. It’s not the nausea some get with strong let-downs, or the pain that many experience with postpartum uterine involution. It’s not a psychological response, which would actually be postpartum depression.
So, what is it? It’s a feeling of dysphoria (the opposite of euphoria), a “yucky” feeling of hopelessly needing to get away that accompanies let-down and often disappears once the milk is flowing, but can recur with subsequent let-downs. Sometimes, it can even feel strangely similar to the feeling of homesickness. Women can get relief by keeping distracted while nursing, trying nutritional supplements or herbs as suggested in the links below, placenta encapsulation, acupuncture, exercise, consuming small amounts of caffeine, and getting more sleep (I know, good luck with that, right?).
- “D-MER” – Nichole’s story
- D-MER.ORG – “Because breastfeeding shouldn’t make you feel this way.” The link to the organization’s blog is here.
- “D-MER (No, You Are Not Crazy)” – Mama Bice
- “Dysphoric milk ejection reflex: A case report” – Alia M. Heise and Diane Wiessinger
“Over the years, far too many women have been wrongly told they had to stop breastfeeding. The decision about continuing breastfeeding when the mother takes a drug, for example, is far more involved than whether the baby will get any in the milk. It also involves taking into consideration the risks of not breastfeeding, for the mother, the baby and the family, as well as society. And there are plenty of risks in not breastfeeding, so the question essentially boils down to: Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than formula feeding? The answer is almost always: Almost never. Breastfeeding with a little drug in the milk is almost always safer. In other words, being careful means continuing breastfeeding, not stopping.” – “You Should Continue Breastfeeding (Illness in Mother or Baby” by Jack Newman, MD, FRCPC
Newman further explains that not only is the advice to stop breastfeeding usually wrong, it’s also “impractical” as pumping and bottle-feeding are not always easy or feasible. If the mother realizes she is sick (with viral infection, bacterial infection, even strep throat), by this time she has already exposed her child to the sickness during stage of contagion. Passing along the antibodies in her milk will protect the child or at least allow for milder symptoms should he get sick, too. The mother can in this way think of having the double role of both patient and doctor. Foodborne or waterborne illness is also not a reason for a mother to stop breastfeeding; in fact, increased nursing can protect the child, according to the CDC.
- See “Medications” under the Contraindicated menu tab
What are they?
“Controversial, hated, overused,” at least according to LLL. Now, this is not the kind of nipple shield we’re talking about:
Breastfeeding shields are silicone nipples that fit on top of a woman’s nipples. Like this:
They should be used short-term with a plan to wean and in most cases, not used during the first week after birth (though this is often recommended by ill-informed health care workers). Proper use of a nipple shield is crucial, otherwise poor milk transfer is a concern (and thus prompts a possible cycle of poor weight for baby, and mastitis or plugs for mom). A good lactation consultant is usually the best person to instruct on proper use and how to wean from the shields when it’s time. If there is no medical indication to introduce a breast shield–don’t! Why not? Per La Leche League:
“Since the infant has to rely on suction alone to transfer milk, these types of nipple shields can drastically reduce his milk intake, potentially causing slow or inadequate weight gain. There are reports that even the thin silicone nipple shields cause reduced milk intake and present a potential for reduced maternal milk supply and nipple damage with improper placement.”
I should have probably listened to LLL on this one. Read my post “My One-Nurse Stand with a Nipple Shield.”
What situations might warrant beneficial use of a nipple shield?
Physical abnormalities, physical barriers in preemies, or deformities in the baby that affect latch. Or, otherwise insurmountable latch issues due the following: flat nipples or abnormal nipple shapes, excessive and constant engorgement, inability of an infant to recognize the mother’s nipple due to bottle-nipple or pacifier confusion, and to protect nipple injuries as they heal.
- “Nipple Shield” – Diane Wiessinger, MS, IBCLC
- “Nipple Shields” – Kelly Bonyata, MS, IBCLC
- “Nipple Shields” – instructions,Barbara Wilson Clay, BSEd, IBCLC for Medela
- “Nipple Shields: Cautions & When to Use” – Ask Dr. Sears
- “Nipple Shields: life-saver, supply -wrecker or just another tool for nursing mothers?” – Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM
Phenylketonuria in Infants (PKU)
PKU is a rare, inherited amino acid metabolic disorder that’s routinely checked for as part of the newborn screening; babies with PKU cannot easily break down the amino acid phenylalanine. Milder forms of the disorder may not need special treatment, though the “classic” type requires a diet with minimal phenylalanine. As breast milk contains very little of this amino acid, it is considered both possible and safe to breastfeed, however most babies will still require a special medical formula in addition to breast milk.
Beginning treatment for PKU before three weeks of age is important as mental retardation is a symptom of untreated PKU. A study measured later IQ as significantly lower in babies who received delayed treatment compared to healthy peers, while those who were treated in the first three weeks showed no comparative difference in IQ with the same group. Detection of PKU via urinary genetic screening also offers an opportunity for developmental and functional improvement in children with autism or atypical childhood psychosis when they’re put on a low-phenylalanine diet.
- “Amino Acid Disorders” – Newborn Screening Info
- “Maternal PKU and Pregnancy” – Organization of Teratology Information Specialists
The prevalence of prematurity has been rising, with now 1 in 8 U.S. babies born at any point prior to 37 weeks of gestation. This is an especially devastating statistic given than the number one killer of babies is prematurity.
How many of these statements do you think are true about preemies?
- Premature babies need to be in incubators.
- Premature babies all need fortifiers.
- Premature babies cannot go to the breast until they are at 34 weeks gestation.
- Mothers of premature babies need to use nipple shields to get their babies latched on well and getting milk well.
- Premature babies need to learn to take a bottle which teaches them how to suck.
- Premature babies get tired at the breast.
- Test weighing (weighing the baby before and after a feeding) is a good way of knowing how much milk the baby got at a feeding.
- Premature babies need to continue getting fortifiers once they leave hospital.
According to Dr. Jack Newman, they’re ALL MYTHS about premature babies and breastfeeding. He elaborates upon each one here. Premature babies need the benefits of breast milk and breastfeeding even more than full-term ones without medical problems. Though donor milk is a great option, keep in mind that pasteurization removes the infection-fighters in fresh milk so try to pump your own milk for your preemie if possible and prioritize alternative feeding methods over bottles.
Some babies, those classified as Very Low Birth Weight (VLBW – under 1500 gms/3.5 lbs) may require a prepared human milk fortifier for growth in addition to breast milk. The risks of feeding formula virtually always outweigh the benefits for preemies, which include ease of availability, greater convenience for doctors and parents, faster weight gain for the baby, and possibly lower financial expense. The risks of feeding formula rather than breast milk to a VLBW baby include, among other things, sepsis and necrotizing enterocolitis.
Did that last thing sound kind of scary? Well, you should really know about necrotizing enterocolitis (NEC), the “most common life-threatening gastrointestinal emergency” facing preemies in the NICU. A diet of exclusive human breast milk can lower the risk of NEC by 79% percent. (Wait, how much??). Best for Babes gives us some fast facts about NEC: It’s an excruciatingly painful disease of the bowels that involves necrosis (tissue death) of parts of the intestines. About 500 babies die from this largely preventable disease every year–about 1 in 7 cases of NEC ends in death.
New science has proven that “digested formula but not digested fresh human milk cause[s] death of intestinal cells in vitro,” with significant death of neutrophils (an essential part of the immune system) ranging from 47-99% with formula versus 6% with breast milk.
But guess what–nearly 60% of NICUs in the U.S. don’t use any donor milk for their vulnerable preemies, and many don’t even mention to new parents that it’s an option! So, how can YOU help? Donate milk, donate funds, and educate your health care providers! Find out how you can save babies from NEC through Best for Babes’ Miracle Milk program, and get details about donating milk in this section of MMNC.
Kangaroo care (skin-to-skin, nestled between the breasts around the clock if possible) is fortunately becoming more popular as a method of improving and stabilizing a preemie’s health. Dr. Nils Bergman describes the “original” paradigm (as opposed to one born from cultural traditions) of breastfeeding and infant care as characterized by “niche and habitat.” Niche includes the basic needs (oxygen, warmth, nutrition and protection) and habitat is the setting wherein these needs are fulfilled. Let’s consider what Lisa Albright wrote about it:
“Anthropologists theorize humans appear to be born about one year ‘too early.’ For many mammals, brain size at birth is about 80 percent of adult size, whereas that of humans is about 25 percent. Humans don’t achieve 80 percent of adult brain size until approximately 21 months gestational age or 12 months postpartum. It has been suggested that this is an evolutionary compromise to the narrowed pelvic structure of humans as they began walking on two legs: the human newborn completes its gestational brain growth outside of the womb. The correct habitat or place for this is being in skin-to-skin contact with the mother, with breastfeeding providing the human milk that is uniquely adapted to the needs of the human infant’s ‘immaturity.’ Up to a point, prematurity can be thought of as an early transition to a habitat that is already designed to cope with human infants’ immaturity.”
This habitat continues to be crucial throughout the Fourth Trimester. Haven’t heard of it? Read more about external gestation in my section here. Bergman explains the relevance of kangaroo care to this theory:
“[T]he human newborn’s natural habitat is maternal-infant skin-to-skin contact. All newborn mammals that have been studied exhibiting a sequence of behaviors that leads to the initiation of breastfeeding. The newborn’s actions elicit a set of care-taking responses from the mother. He emphasized that breastfeeding is a niche, or set of pre[-]programmed behaviors, which the mammalian newborn exhibits that are appropriate for its habitat. Thus in the newborn habitat, the newborn gets oxygen through the air, warmth and protection through skin-to-skin contact with the mother, and nourishment through breastfeeding.”
Albright says Dr. Bergman’s case is that “the current paradigm of separation of the infant from its mother…has turned prematurity from an early habitat transition into a disease state.”
- “Breastfeeding a Preterm Infant After NICU Discharge: Reflections on Ryan’s Story” – Paula P. Meier, RN, DNSC, FAAN
- “Breastfeeding the Late Preterm Infant…” – The Academy of Breastfeeding Medicine
- “Breastfeeding My Premature Baby” – Laura Colon-Liebergen
- Breastfeeding Premature Infants categories by LLLI; includes stories and articles
- “Kangaroo Mother Care: Easing Baby’s Transition into the World” – Teresa Pitman
- “Kangaroo Mother Care: Restoring the Original Paradigm for Infant Care and Breastfeeding” – Lisa Albright
- NEC Society web site
- Preemie posts list by Kellymom
Postpartum Mood Disorders
This section is still in progress. Check back soon.
What’s the difference between “relactation” and “induced lactation”?
If a woman stops breastfeeding a child and wishes to later produce milk for him/her, or another biological or adopted child, the process is called relactation. The possibility of exclusive breastfeeding is herein very realistic. Induced lactation is what can happen if a woman who has never been pregnant wants to produce milk. Exclusive breastfeeding is often less realistic in this case, but of course any amount of regular breastfeeding is better than none.
How does it work?
- “From bottle to breastfeeding: a hard journey to contentment” – Sylvia Thompson
- “Relactation and Adoptive Breastfeeding: The Basics” – Kelly Bonyata, BC, IBCLC
- “Relactation Boot Camp” – Adoptive Breastfeeding Resource Website
- Relactation stories – LLL
- “The Road Back to Breastfeeding and Beyond” – blog journal by MommyHopeful3
- The Breastfeeding Mother – blog with relactation/SNS system info
Considerations for same-sex parents:
- What will happen with your parental leave at work, if any?
- In a woman/woman partnership, will one (or both) of you breastfeed or express milk?
- In a man/man partnership, from whom do you intend to procure human breast milk for your child–the birth mother (decisions about breastfeeding and/or short-term or long-term pumping must be stipulated in your contract) or an outside donor?
- In what ratio to do you plan to supply milk options (human or alternative) for your child, if any?
- “Co-Nursing: How Two Moms Can Breastfeed Baby” – Medela Moments
- “Guidelines for Heathcare Providers Working With Same-Sex Parented Families” – The Bouverie Centre at LaTrobe University in Victoria
- “Induced Lactation for the Nongestating Mother in a Lesbian Couple” – a commentary on ethics from the perspective of Lance Wahlert, PhD and Autumn Fiester, PhD
- Milk Junkies – an eye-opening blog about breastfeeding and parenting from the transgender perspective
- “Why I’m a Breastfeeding Dad” – Trevor MacDonald
- “Mothers’ Milk: Two-Parent Co-Nursing in Queer Families” – Jules Moon, Bachelor’s Research Project in Midwifery
Teenage mothers are less likely to breastfeed than any other population. Those who did continue to breastfeed longer than six weeks report “significant emotional, informational and instrumental support from family, friends, school, and their babies.” Teenage mothers who consider breastfeeding have special concerns such as whether nursing will “ruin” their breasts and how it will affect their bodies, their usual social activities, relationships with boys, friends, and the baby’s father, attending school, potential regular habits such as exercise, smoking, and birth control pills, and fears about nursing in public.
The AAFP says that doctors are on the frontlines of support for pregnant adolescents, especially given our society’s largely shaming attitude about young motherhood.
“Pregnant and breastfeeding adolescents often have significant concerns about body image. These concerns can be addressed by providing positive images of discreet breastfeeding and educating them about changes that will occur during pregnancy and breastfeeding. Often, teenagers are disinclined to bring up such concerns, but if asked they are willing to discuss body image concerns, as well as issues such as sexuality and contraception. Because teenagers worry about their changing bodies, it is important to proactively share information about proper nutrition, diet, exercise, and weight loss with the mother and those in her support system.
Milk production in teenagers has been evaluated because of concerns about a possible decreased milk supply in adolescent mothers.They may make less milk as a result of having less breast tissue. Teenage mothers often feed their infants less frequently and supplement with solids earlier.However, most teenage mothers with proper support have ample milk supplies.”
In Amy Spangler’s book Breastfeeding: A Parent’s Guide, you’ll find a whole chapter devoted especially to teenagers who want to breastfeed (pgs. 35-43). What teens say in the book:
“I feel proud that I breastfeed. Many people said that I am too young to breastfeed. You are never too young. I mean, if you have a baby, you are not too young to breastfeed.” – Lee
“…Just try it. If you find that you have problems, do not give up real quick…Clear your mind of all the advice, and all the wrong ideas you have been given about breastfeeding. Start fresh. Know that it is best for your baby to breastfeed and that you are going to do it.” – Kayla
“There are no rules to breastfeeding. You can breastfeed wherever you feel comfortable. Don’t worry about what other people think. Your baby needs to eat like everyone else…” – Maggie
“Don’t worry about having to go to school because you can still breastfeed in between. If you’re just going to breastfeed at night, that’s better than not breastfeeding at all.” – Faith
Check out these articles by Jacqueline Levine LCCE, FACCE, CD(DONA), CLC:
- “Encouraging Teen Moms to Breastfeed” – Kelly Bonyata, BS, IBCLC
- “Helping Adolescent Mothers Breastfeed” – Bonnie Tilson
- “Promoting Breastfeeding in Teen Moms” – Lily L. Carter, RN, BSN, PHN, CLE (pg. 5)
A reported 27% of childbearing-aged women were sexually abused in childhood, and an estimated 40% including adolescent/teen years. According to LLLI, 90% of abusers are male 70-90% are known to their victims; and for girls, 30-50% of abusers are family members.
In a nationally representative sample study, women who self-reported past sexual abuse were more than twice as likely to initiate breastfeeding. However, women who were or are currently sexually abused are at greater risk for postpartum depression, disturbed sleep, and perinatal complications. Night feedings are often especially frightening for a survivor of abuse. Exclusive breastfeeding has been shown in a study to reduce rates of depression and poor sleep among survivors, as compared with formula feedings and mixed feedings (read about the study’s background and a podcast interview with the author here).
Karen Wood, PhD, who notes that 1 in 3 to 1 in 5 Canadian girls are sexually abused in childhood, observed this in her paper “Infant feeding experiences of women who were sexually abused in childhood”:
“A history of [childhood sexual abuse] can affect a woman’s experience of breastfeeding, including acting as a trigger for remembering or re[-]experiencing the abuse. Women who were sexually abused as children need to experience a sense of safety, acceptance, sensitivity, and understanding.”
How some women with histories of sexual abuse feel about breastfeeding:
“I think a part of my experience was that I didn’t really have a body. I was a head with legs. Or with feet. I was just kind of a walking turtle … I ignored everything in between .… I remember the breastfeeding. I remember the frustration. But I can’t say I remember any feeling from it—physical sensation. I didn’t register any body sensation anyway. I was just—the breasts were functional for that time.”
“With my first pregnancy I didn’t know that was going to happen. I didn’t know all of these hands would be down there while I was delivering—in the vaginal area. Because that’s how I was molested when I was 5. So I was very traumatized thinking about the delivery. Not about the pain, but about the other person touching.”
“And everything was so new, and it was, but in a wondrous way, not in a rejection way, like I have always rejected my body. But in a wondrous way! You know how it’s almost like seeing things for the first time? It was so strange.”
- “Breastfeeding After Sexual Child Abuse” – PDF by South Eastern CASA
- “Breast Feeding and Sexual Abuse Survivor” – Family Research Laboratory, University of New Hampshire (Domestic Violence Information and Services)
- “Breastfeeding and the Sexual Abuse Survivor” – PDF by Kathleen Kendall Tackett, PhD, IBCLC
- “Breastfeeding and the Sexual Abuse Survivor” – for leaders, by LLLI
- “Breastfeeding as a Rape or Sexual Abuse Survivor” – Katy, Pandora’s Project
- “Breastfeeding as a Survivor of Sexual Abuse” – Morgan Gallagher
- “How a History of Sexual Abuse Affects Breastfeeding” – Booby Traps Series by Best for Babes Foundation
- “Laboring to Mother in the Context of Past Trauma: The Transition to Motherhood” – Helene Berman et al., University of Western Ontario
Read my post on tandem nursing here. (Includes resources/links).
Tongue/Lip Tie (ankyloglossia)
This condition is a midline facial defect that likes to run in families. The effects of a tongue or lip tie can severely affect breastfeeding; in fact, it’s a common cause of otherwise unexplained maternal pain and early cessation of breastfeeding, whether the mother (or a health care practitioner) knew about it or not. Read more more about the breastfeeding consequences here. The American Academy of Pediatrics has also finally recognized the reality of congenital ties in this newsletter. Per Dr. Lawrence Kotlow, DDS:
“Infants are often born with a combination of [these] conditions… A tongue tie occurs when the embryological remnant of the tissue attaching the tongue to the floor of the mouth does not disappear when an infant is born. A lip tie is when the upper lip remains attached to the upper gum.”
Class 1 – tie is at the tip of the tongue
Class 2 – tie is just behind the tip of the tongue
Class 3 – tie is near the tongue’s base
Class 4 – tie may be covered by mucosal membrane and cannot be diagnosed by sight alone (this video is helpful in determining whether posterior tie is the issue)
Class 1 – tie is minimally visible
Class 2 – tie is mainly attached to gingival tissue
Class 3 – tie attaches just before the hard palate
Class 4 – tie reaches into the hard palate
In Kotlow’s online booklet, learn about ankyloglossia myths, examination criteria, surgical release methods, post-surgery care, and see PHOTOS of tie examples. This video demonstrates how to care for a tie day-by-day after it’s been surgically released. Read about special aftercare and important stretching exercises here.
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