Early Postpartum

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BE PRESENT

Welcome to the start of the 4th trimester. Early postpartum is a critical but challenging time period for establishing milk production for your baby.  Moms and babies may be sleepy from birth, or recovering from unexpected or traumatic events.  The birth experience can be physically and emotionally exhausting in itself, which then transitions into significant sleep deprivation in the first week or two postpartum.  

Partners can be overwhelmed as well, and often wonder how they can help a mom who is struggling. If a mom is breastfeeding, partners can help by doing EVERYTHING ELSE: laundry, meals, dishes, walking the dog, bringing things to mom, doing skin to skin, errands, and and more.

Women can move from frequent obstetrician visits toward the end of pregnancy to infrequent contact with the medical system aside from pediatrician visits that are focused mainly on the infant. In the wee hours of the morning, women turn to the internet for advice about their breasts. 

While my hope is that we ultimately build healthcare and community programs that support all aspects of the breastfeeding dyad with scientific lactation advice, this section outlines principles of early postpartum lactation support. Many topics discussed in this section apply to other time points in breastfeeding as well.

Skin to skin contact with baby

As much as possible, I encourage patients to avoid internet searches, apps that track feeding, and everything else that may distract them from simply being present with their baby and their own experience.  

If moms are struggling or unsure of what advice to follow, it is best to seek in-person medical or lactation consult. 

Further, it’s better for both mom’s mental health and infant development to talk face-to-face with other moms, rather than comparing anecdotes virtually.

Breastfeeding in early postpartum stage

An example of how internet “lactation lore” can be reported and then repeated (just like any other “false news” on social media) is the idea that fenugreek, a galactagogue used for hundreds of years, “decreases milk supply.”  I talk with patients about the idea of “confounders” (multiple different factors at play in a certain scenario) and new moms not recognizing other personal factors at play as they express their frustrations to the virtual world.

For example, a mom using fenugreek very likely has noticed a drop in breastmilk production — or she wouldn’t be using the herb at all.  This same mom could, for example, have had return of her menstrual cycle.  This is an event known to significantly drop milk production.  But the mom blames fenugreek – when it’s actually the menstrual cycle to blame.  Moms also may not report that, for example, they are pumping less or feeding the baby less, or sleeping overnight.  Even with using fenugreek, production will decrease in any of these situations.

There are innumerable other instances of this type of information that can misinform decisions moms make for them and their babies. Instead, I would rather have moms try to enjoy the experience (there’s so much that’s hard about parenting, and we don’t want to make it harder!), trust themselves, and seek professional advice.

Phone Holiday!
Send your phone on a "phone holiday"!  Put it in a shoebox for 12 hours one day and make note of how you're spending your time, and when you feel the urge to google search or check social media.  People often don't realize just how much they are paying attention to a screen rather than getting to know their baby and just having free headspace.  I ask patients if they feel better "before or after they have been on google or social media" -- and it's always worse.  Babies grow up too fast -- don't waste it on a screen!

Skin to Skin

As outlined in the Pregnancy and Birth section, skin-to-skin contact time is essential for mom and baby’s blood pressure and temperature stability after birth as well as establishing breastfeeding.  It is impossible to overdo skin-to-skin time. Partners can help soothe and introduce the baby to the world from the comfort of cuddling at their chests.

Early postpartum breastfeeding
Early postpartum breastfeeding
skin to skin contact with newborn
Skin to skin contact with newborn

Sleepy Baby

Babies can vary from very sleepy to much more alert.  This variability is related to a wide variety of factors including gestational age, weight, method of delivery, length of labor, epidurals and other pain medication.  If a baby remains very sleepy after the first few days, the infant and mother’s milk production should be investigated.  A sleepy baby will only become more sleepy and lethargic if he is not transferring enough breastmilk, and mom’s breasts also then do not receive the stimulation they need. 

Sleepy baby breastfeeding

Moms may be offered a nipple shield in this situation, so it is important to have a lactation consultant help you understand when the infant is swallowing. Sucking the nipple shield like a pacifier without swallowing means the baby is burning calories without transferring milk. Nipple shields also prevent normal stimulation of the nipple and breast tissue, and can result in delayed or lowered milk production. 

Ideally, with a very sleepy baby, moms should pump to help stimulate their breasts and provide milk to their infant with a cup or bottle, and then continue to offer the breast without the shield for “practice” until the baby is more awake and getting enough calories.

Taking off baby’s clothes, tickling its ears or toes, burping, and changing diapers are all interventions that are not effective in arousing a baby if mom’s milk is less than what a baby needs, or delayed in “coming in.”

Babies need FLOW of milk to be stimulated. You can do gentle compressions of your breast tissue to “pump” milk into the infant (this is truly a pump-like motion in the part of your breast near your chest wall rather than a squeezing/sliding motion toward your nipple).

Otherwise, you should remove an infant from the breast and supplement appropriately.

You also can supplement some volume prior, which is called “finishing at the breast.”  This allows babies to take in some calories as an “appetizer” and have energy to be more active with breastfeeding.  

I describe this to patients as trying to run a race with or without any energy from food/calories.  You can run longer/faster if you have some calories/energy first.

“Milk Coming In” and Engorgement

Lactogenesis II is the onset of milk production (“milk coming in”) after the initial colostrum production.  This occurs approximately day 3-5 after birth, at which point mom’s breasts become more engorged and the baby will start to take in larger volumes of milk.  

This is a time period where the mother could experience increasing pain or nipple trauma due to the engorgement and difficulty in the baby struggling to latch.  I describe this as a “water balloon” effect and can be particularly challenging in large breasts or breasts that have undergone previous augmentation surgery.  Lymphatic drainage can relieve pain and swelling, and feeding in the side lying position as detailed below is also helpful.

Postpartum day 6 engorgement. Note the faint red appearance of both breasts, representing congested blood flow and connective tissue fluid — not mastitis.
Significant postpartum engorgement day 5.
Significant engorgement postpartum day 4 with lymphatic congestion visible right breast lower inner quadrant and faint redness (edema) in both breasts lower quadrants
Significant engorgement postpartum day 4 with lymphatic congestion visible right breast lower inner quadrant and faint redness (edema) in both breasts lower quadrants.
Sirilak Thavornwattana, Pediatric APN, Thailand
Sirilak Thavornwattana Advanced Nurse Practitioner (APN) Pediatric Nursing

Significant engorgement early postpartum (Sirilak Thavornwattana, Pediatric APN, Thailand).

Position and Latch: It’s All About the POSITION!

So much of the lactation world has focused on “achieving the perfect latch.”  However, it’s time to change the conversation.  The bottom line is no comfortable latch can be achieved without the right POSITION.

Cradle hold (baby nursing from same breast that mom is holding with).
Cradle hold (baby nursing from same breast that mom is holding with).
Breastfeeding in front of a Christmas tree

The REAL solution to a “good latch” is a change in positioning.  

While the cross cradle or cradle hold is most often visualized as the “classic” nursing position, the football hold may be easier for moms with larger breasts.   

In addition, there is no problem with a latch, no matter what the baby looks or sounds like, if mom is comfortable, baby is comfortable, and baby swallows and gains weight/stools appropriately.  Babies may not always (or ever) relax their lips.  This is ok.  

They may clamp more if they are dealing with a higher flow; it’s their way of preventing themselves from getting drowned in the “garden hose.” They also may clamp at the breast if they are frustrated with a lower flow.

However, my favorite nursing position for larger breasts and/or lots of milk is the side-lying position.  It slows down flow (instead of dealing with a garden hose directed vertically from mom’s breasts, infants can nurse in a gravity-neutral position and take breaks).  Babies will clamp less and generally feel more comfortable when they aren’t fighting the weight of mom’s breast and milk flow.

Young baby breastfeeding
Young baby breastfeeding
Newborn breastfeeding
Newborn breastfeeding
Mom’s head is resting on pillow. Propping weight on arm is uncomfortable, so it should rest on bed as demonstrated here.
Mom’s head is resting on pillow. Propping weight on arm is uncomfortable, so it should rest on bed as demonstrated here.
side lying nursing

Moms should lie with their head on a pillow, relaxed.  The “down” arm (next to the bed) can curve around baby to cuddle, and the “up” arm (away from bed) can help latch the baby.  Even if moms don’t have larger breasts or high flow, the side lying position is extremely comfortable and allows mom to cuddle with and nurture the baby without hunching over a nursing pillow or other nursing device.

Another great position is laid back, or “biological” nursing.  However, mom must START on her back and let baby take full advantage of gravity.  Often, moms are taught to latch baby and THEN lean back.  Any baby latching in the upright cross cradle position will still clamp, even if you later lean back.

True laidback position for breastfeeding
True laidback position
Laid back nursing position (though mom should be flatter on back if her milk flow is high).
Laid back nursing position (though mom should be flatter on back if her milk flow is high).

Do NOT Time Feedings

Babies should suck and swallow, be content after, and be gaining weight and urinating/stooling appropriately.  If you have enough milk, or even too much milk, the baby does NOT need to feed off both breasts for a prescribed period of time.  Likewise, if you are struggling to increase your milk production, the baby should only be on the breast to suck and swallow, and then be switched to the other breast.  Both mom and baby will become exhausted, and the baby will burn calories and lose weight, if feeding for a prescribed period of time (for example, “15 minutes per side”) without swallowing and transferring milk.

If a baby is gaining well and sucking and swallowing and then relaxing/cuddling at the breast, it is ok to let babies find comfort this way.

Mom breastfeeding in public

Flow Sensitive Baby

Sometimes babies can be sensitive to the breastmilk flow they need at the breast.  

I call these the “goldilocks” babies:  flow can’t be too fast, it can’t be too slow — it has to be “just right.”

goldilocks baby

If it becomes a pattern that they want fast flow from a bottle, despite mom’s adequate breastmilk production, the babies often have to be “tricked” into being more patient at the breast.  

This can be accomplished with “finishing at the breast” (providing some supplement prior to breastfeeding, so babies associated the breast with satiety, not the bottle).  If this does not help, focus on pumping to maintain your milk production and feed the baby at times when he is sleepy (i.e waking up from naps or dream feeding overnight).  

If a baby is sleeping through the night naturally, he may become more ravenous for fast flow during the day, as he needs to feed more then to make up for lack of nighttime calories.  If you can add an overnight feed at time when the baby will be more patient, this can help reintroduce the breast as well as take the edge off daytime hunger.  

However, the vast majority of the time, mom appreciates her sleep and adding a feed when a healthy baby is sleeping can disrupt physiology. Often, a better approach is reassure mom that the increased feeds during day is normal if the baby is gaining weight well.

Flow sensitive pre-term baby in NICU, gaining well with mom’s ample production and fast flow.

Nipple Shape

Nipples most often do not look “picture perfect.”  Depending on the underlying elasticity (“stretchiness” or “compressibility”) of your nipple tissue, some nipples may look flat, “lipstick shaped” or otherwise look like they have been nursed on.  Unless you have pain, trauma, or the baby is not gaining weight well, this is NOT a problem.  If you have pain or trauma, this may be related to overproduction of breastmilk (the baby clamps to control flow) or lower production (the baby is working so hard at the breast for so long that he stretches/compresses the nipple).

It also can be related to positioning in larger breasts or high/low milk production.  Any baby will clamp and hang on if it is struggling under the weight of a large breast.

The bottom line is a “perfect” nipple is NOT a reality, nor should it be.  

Nipples are just one part of the organ system of our human body. Everyone’s skin, connective tissue, and muscles are different:  stretch marks, wrinkles, vaginas, anuses, and all else (including nipples and breasts!) are unique.

This very stretchy nipple does not look rounded after nursing, but mom has no pain and baby is gaining well.
This very stretchy nipple does not look rounded after nursing, but mom has no pain and baby is gaining well.

Nipple Shields

Baby breastfeeding without a nipple shield
Baby breastfeeding without a nipple shield

If you are offered a nipple shield in the hospital, be cautious.  Any infant will reflexively suck a firm stimulation of their palate (shields, fingers, bottles).  

It is like introducing a pacifier at the breast, despite the fact that moms are often told to avoid other pacifiers and bottles.  It is contradictory to have a mom using a syringe to “finger feed” an infant and prevent “nipple confusion” while using a nipple shield at the breast.  If you have been sent home from the hospital doing this, stop immediately and give a bottle if needed!

Nipple shields are a marker for other issues that should be explored such as the following:

#1:  Larger breasts and the “water balloon effect.” Moms with larger breasts often have nipples that will flatten when mom is in an upright position. The baby cannot possibly latch against the “water balloon” (nor can an adult human!).  They clamp and struggle, causing nipple damage.  Or they simply refuse to latch and cry or fall asleep.  If this sounds like your situation, ask someone to demonstrate side lying nursing.

Side lying also allows the nipple to become more firm, as all nipples contain erectile tissue just like the clitoris or penis.

#2:  Nipple shields make a baby to latch to a breast producing too little milk or colostrum:  Babies  may be sucking, but not swallowing milk.  

This makes babies burn calories and negatively impacts milk production.  Prolactin (the milk-making hormone) levels can plummet rapidly in the first week of life if mom is using a shield around the clock and not getting any other breast stimulation.

No amount of jaw motion, cheek sucking, “pouching” or other visual cues substitute for the sound of swallowing and a baby that is engaged with nursing then satisfied after a reasonable feed (sucking for 45 minutes or an hour with little swallowing is concerning).

#3: Nipple shields may be offered when a baby is drowning in the “garden hose” effect of mom with engorgement and lots of early milk.  

Rather than using a shield, the first step is to feed side lying and help your nipple become erect (stimulate your nipple, give gentle compression to the areola to help the fluid drain – “reverse pressure softening”).  If oversupply persists, you should be evaluated by a healthcare provider to discuss interventions for hyperlactation.

#4: There are some situations where a mom is so anxious about trying to make breastfeeding “work” that the baby feeds off of this anxiety and immediately becomes fussy when brought to the breast.  If the mom feels more confident with a shield and this means the baby will actually latch and relax, a mom just needs to be aware that the nipple shield is an EMOTIONAL crutch, NOT a physical crutch.  These are moms with normal nipple/breast anatomy and babies with normal oral anatomy who take bottles, pacifiers, and fingers easily.

In these situations, it’s important to prioritize mom’s mental health and help her understand shield time is no breast stimulation time and potential calorie burn time for baby.  As long as she is aware (the real danger of shields is people thinking that babies are actually getting lots of milk), everyone can land in a place that feels best individually.

#“Getting off” a nipple shield that has been initiated in the hospital can take time, even up to several weeks.  

Sometimes allowing a baby to nurse with a shield for a few minutes then removing the shield and continuing to nurse without it is the best approach.  Other babies may take the breast if mom changes to side lying position.  I often have moms pump to maintain their milk production and offer the breast without a shield a few times a day in between bottles.  It can be too exhausting for moms to fight an infant that doesn’t want to latch every single feed, but it’s also counterproductive to let the infant latch at the breast with a shield that doesn’t stimulate mom’s breasts and represents passive milk transfer for the baby.

 

Pooping

Babies should finish passing their meconium (dark, tarry stools that occur just after birth) by 72 hours.  After this, they will experience transitional stool (brownish yellow) and then develop bright yellow, seedy stools.  An approximate rule is they should have the number of stools corresponding to their day of life (e.g. five stools per day at day five).  Yellow, seedy, liquid stools are normal for breastfeeding babies.  While they will stool less frequently as they get older (see 6 weeks to 6 months) and this is normal, less stooling than expected in the initial first week or two postpartum is a sign of them not consuming enough breastmilk and the babies should be evaluated for adequate milk transfer and weight gain.  Wet diapers are a less reliable sign of intake as babies will naturally diurese (eliminate extra fluid through urine) after birth.

Dark poopy Diaper
poopy diaper
Transition from meconium (black, tarry) to transitional (brownish) to yellow, seedy (mature stool)

Weight Loss

Normal weight loss involves less than <7-10% of birth weight at day five for exclusively breastfed babies All babies will lose some amount of weight and then start to regain the weight.  If mom is producing enough milk, babies should regain their birth weight by two weeks.  After this point, the goal is approximately one ounce (20-30 grams) per day of weight gain until three months of age.  

It is not uncommon for first time moms, particularly those with a difficult labor or c-section birth, to have some delay in their “milk coming in” (i.e. the transition from low-volume colostrum to higher volume early milk).  If you are concerned you may have some struggle with milk production based on your medical or surgical history, you may want to hand express colostrum prior to delivery and store it for use at the hospital (see Pregnancy and Early Postpartum).  You can also utilize donor milk, though informal sharing requires attention to safety. If formula or formal donor milk is indicated for the safety of the baby, the hospital doctors will provide this.

Deepa Joseph and Ingrid Oxley of the Texas Children’s Hospital Milk Bank.
Deepa Joseph and Ingrid Oxley of the Texas Children’s Hospital Milk Bank.

"Hindmilk and Foremilk Imbalance"

There’s no such thing as “inadequate calories in breastmilk.” While breastmilk does vary among individuals (and even among different infants of the same mother), it nevertheless has all the components an infant needs for normal growth and development. Further, there is no such thing as “hindmilk” and “foremilk” imbalance as a source of inappropriate growth in babies. This delineation between the “less fatty” milk at the beginning of a pump or feed versus the “more fatty” milk at the end is much less distinct in terms of overall 24 hour feeding than most people think. 

Infants that truly are taking adequate volume may just be smaller people like their parents (birth weight and growth vary among ethnicities).

Otherwise, they need to be investigated for other causes of low weight gain such as increased metabolic demand (e.g. unrecognized congenital heart disease). The answer to low weight gain despite adequate breastmilk transfer and breastmilk volume is NOT FORMULA.  This will simply drive down baby’s interest in taking volume and the breast and prevent  identification of the real issue (just a smaller baby on the curve of normal or an actual medical diagnosis).

On very rough average (again, volume is related to individual variation of mom’s milk and time postpartum) newborns need approximately 2-3 ounces every 2-3 hours. For older breastfed babies, this volume can vary from 2-5 ounces depending on duration between feeds.

Young baby breastfeeding

Surrogacy and Donor Milk

Parents who utilize a surrogate mother for carrying the baby can also arrange to utilize her donor milk for a period of time.

For questions regarding induced lactation, see link under Pregnancy and Birth section.

Dr. Mitchell's medical school roommate, his husband, their newborn baby and surrogate mom.
My medical school roommate, his husband, their newborn baby and surrogate mom.

Pumping

Mom pumping breastmilk

Pumping has developed into a complicated adjunct to breastfeeding, when in fact it should be very simple (why make anything harder than it already is?). In some situations, moms must pump (NICU baby, working/away from infant, very low production when baby won’t latch to breast). However, everyone else should “dump the pump” when possible. Kimberly Seals Allers, a fantastic journalist and maternal-infant health advocate has has said that “we are a pump nation” and instead of advocating for better pumps, we should be focusing on appropriate paid maternity leave.

Simple Rules:

  • Do not pump to relieve engorgement or keep breasts empty. This just stimulates more milk production. If you are pumping to replace a feed at breast, pump only what baby needs for that feed (e.g. 3 ounces).
  • Pump no longer than 15 minutes. It is better to pump more frequently and for shorter durations. Pump every 2-3 hours early postpartum; this can be adapted as mom’s milk production stabilizes. Some women can pump much less frequently, and some require continued frequent pumping.
  • “Power pumping” (when women are instructed to pump for 10 minutes, stop, pump again, stop for a period of an hour or more) only temporarily increases prolactin levels in the body and generally is miserable for moms. It usually is more reasonable to have normal duration pumping sessions frequently throughout the day.
  • Be wary of flange size. There has been a trend in the lactation world recently to use very small flange sizes, and even 12 mm is on the market. It is not a problem if your areola pulls into the flange, as long as it doesn’t hurt or get permanently swollen. Infants also pull the areola into their mouth when they are nursing. The key is no wounds and no pain.
  • Use normal suction levels, or you otherwise risk injury from too high suction.
  • Avoid coconut oil and other lubrication, as this can cause Montgomery Gland obstruction (wipe off lubrication after pumping if you do use it) as well as enable people to turn up suction to dangerously high levels. Your body was meant to have some traction against a pump motor, and to sense if suction is too high.
  • Refrigerate parts between pumping and wash at the end of the day. Breastmilk is not sterile and parts do not require sterilization for healthy fullterm babies .
  • Store milk in separate bags of what an infant would drink (e.g. 3 ounces rather than 10 ounces). Warm at room temperature or in a warm bowl of water. The CDC and Academy of Breastfeeding Medicine have official guidelines regarding breastmilk handling, but an unofficial approximation is the “Rule of 6”: 6 hours at room temperature, 6 days in refrigerator, and 6 months in the freezer (one year for deep freezer).

Cluster Feeding

Be cautious with “cluster feeding.”  In cases with moms with normal colostrum and milk production, this is a normal infant reflex.  However, if mom has low colostrum/milk volume and and the baby is losing too much weight and/or not stooling appropriately, cluster feeding may actually represent a baby hungry and desperate at the breast.  

The key is to understand whether your baby is gaining lots of weight, yet seems to be constantly “hungry” (this is where you want to recognize feeding versus holding/bouncing/pacifier cues) or whether your baby is NOT gaining enough weight (and that baby needs supplement).

Painting of women breastfeeding by Chloe Trayhurn
Chloe Trayhurn

Home Scales to Monitor Infant Weight Gain

Be cautious about using home scales to monitor infant weight gain. They can be inaccurate (professional scales are calibrated by an engineer and not moved), and also can trigger obsessive daily weighing when an infant is actually growing well. In other situations, they can falsely reassure parents weight gain is adequate.

Baby on scale in doctor's office

"Triple Feeding"

Mom breastfeeding

“Triple feeding” (feeding the baby at the breast for a prescribed period of time, then pumping, then giving the pumped milk back to the baby +/- other supplementation with donor milk or formula) is temporary solution to a delay in lactogenesis II (“secretory activation” or “milk coming in”).  

Parents are instructed at the hospital to provide the pumped milk or supplement via a syringe to avoid “nipple confusion.”  However, sustained triple feeding with syringe supplementation quickly becomes exhausting and demoralizing for parents, and exhausting for infants as well.  

Infants should NOT be placed to the breast for a specific period of time (such as 15 minutes per side).  Instead, they should only be at the breast if they are sucking and swallowing, or if they have been supplemented prior to the feed and are “finishing at the breast” for comfort only.

Newborn babies burn calories at the breast when they are not transferring milk.  And the continued sleepiness and lack of stimulation tells your breasts they don’t need to make milk.  Infants get behind in calories, sleepier, and not strong enough to suck.  

If you are discharged from the hospital triple feeding, you should schedule for close follow-up with your pediatrician and/or breastfeeding medicine physician or lactation consultant after delivery.  At this point, your milk production and infant’s weight and stooling should be reevaluated.  Things can change on a daily basis in the first few weeks, and feeding plans may need to adapted to protect both mom’s mental health and infant caloric intake.

The alternative to triple feeding is what I call “divide and conquer”:  Mom focuses on pumping and introducing galactagogues (herbs or medications that increase milk production) to stimulate her breasts.  She reminds them that even if the baby got sleepy and behind in calories, they do in fact need to produce milk.  This is one of the few times where I actually feel a pump is useful and medically indicated (aside from NICU, or other separation of mom and infant).  Dad, partner, or other relative focuses on getting calories in the baby.  

It is OK to give a bottle at this point.  “Nipple confusion” in the setting of low milk production is actually more of “flow preference.”  Babies will either fuss at a breast without enough milk, or fall asleep.  I have mom put baby to breast at times when her milk flow should be higher (i.e. in the early morning hours — even moms with plenty of milk will have less in the afternoon and evening).  This is simply to maintain baby’s familiarity with mom’s breast.  

The baby can suck for comfort, but it is necessary to ensure the baby continues to take in adequate volume from the bottle.  Over time, mom can gradually notice the baby swallowing more and the breast and being more satisfied.  However, this does not happen immediately and can take at least six weeks (and often longer) to change.  Some moms have to continue supplementing for the duration of breastfeeding.

Like all of parenting, breastfeeding is a MARATHON and NOT a sprint.  It is much better to give a baby a bottle to sustain early breastfeeding challenges than become utterly exhausted with syringe feeding and then give up.  

There is NO miracle cure or switch to go from significant supplementation to exclusive breastfeeding overnight.  All circumstances are individual and nuanced.  It is important to have help/support to find a path forward that works for you, prioritizing your mental health above all else.

“Low Supply”

If more than a week has passed and you still are experiencing low production, it’s important to continue to work with a healthcare provider for monitoring you and your baby.  

Some first time moms will simply have delayed lactogenesis II as described above.  These moms are generally noticing continued increase in their production each day.  Other moms may ultimately produce some, but not all, of the milk required for an infant’s appropriate growth (the good news is that the longer mom pumps, uses galactagogues, and feeds baby at breast as she is able, the more milk she will make with each subsequent child).  

Some moms may experience particularly significant low volume production (e.g. 5-10 ounces per day, despite religious pumping and galactagogue usage).  Every situation and mom is different.  What feels right and sustainable for one mom may not be right for another.  It is important to explore your thoughts and feelings.  If you have guilt over stopping breastfeeding in the setting of low production, it is often helpful to seek support for breastfeeding guilt and trauma.

Painting of mom breastfeeding by Chloe Trayhurn
Chloe Trayhurn

If you do choose to continue breastfeeding and pumping, most babies will start to refuse the breast as they grow and realize there isn’t a flow of milk that is acceptable to them.  If this happens, you can try to “finish at the breast” by giving the baby most of her supplement she needs via a bottle first, or use a feeding tube at the breast (more commonly called “SNS”).  

Overall, make a plan that works for YOU (mom always comes first) regarding formula and/or donor milk.

Supplemental Nursing System (“SNS”)

SNS is another option for low milk supply, but it can be challenging to master and most moms and partners tend to find that it adds to their stress and overwhelm.  I tend to ask parents their feelings about the SNS.  If it feels do-able, we work through it and have mom prepare the tube prior to putting baby to breast. IABLE has excellent teaching videos, including one on using a feeding tube at the breast.

IABLE photo showing a supplemental nursing system
IABLE

Postpartum Exhaustion

The postpartum period can be absolutely exhausting for new parents. If you have a baby that likes to be held and doesn’t want to sleep alone, you may be caught in a vicious cycle of having the baby feed, fall asleep, and then suddenly wake up when it is put down in its bassinet on its back. You repeat the drill. It happens again. This can go on all night long.

This is because we are primates, a “carry” species in the mammalian kingdom.  Our babies are born immature and designed to need 24/7 contact with the mother until they get older.  Other primates (gorillas, chimps, baboons etc) would never force a newborn to sleep even one foot away from them — they would die.  Our modern world has developed ways to prevent this from happening to our babies (heat, air conditioning, indoor shelter as protection from predators etc), but it still means our babies are going to behave the way they are biologically wired to do so.

Baboon carrying mammal Baboons, one of our close relatives (and prevalent everywhere I lived in Tanzania!), carry their babies everywhere until the babies are more mature and able to be safe independently.

Parents will often concoct elaborate plans such as sleeping in a rocking chair with a baby on a pillow in order to avoid “bed sharing” or “co-sleeping.” Unfortunately, this approach is more dangerous than bed sharing safely.

Baby may look cozy, but is not in a safe sleep position!
Baby may look cozy, but is not in a safe sleep position!
Safer sleep is on a flat surface with no blankets or pillows near baby.
Safer sleep is on a flat surface with no blankets or pillows near baby.

The Academy of Breastfeeding Medicine Bedsharing Protocol, authored by the world’s experts on safe sleep, outlines safe ways to approach the reality of breastfed babies liking to be kept close to their mothers. James McKenna, a Notre Dame professor whose research focuses on “breastsleeping” has additional valuable resources for parents.  I worked with James McKenna on a patient safety handout, and I was honored when he said that if I ever needed a letter of recommendation, he wanted to provide one.

More recently, The Academy of Breastfeeding Medicine published an extremely useful Bedsharing Handout, as well as a Physiological Parenting Handout. They both offer education regarding human infant behavior, and recommend ways to get more sleep and keep baby safe.

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