A Breastfeeding Q and A

Missy Berggren

Have questions about breastfeeding, from how to up your milk supply to knowing when to wean? Breastfeeding expert Sally Wendkos Olds provides the answers.

This article is reprinted with permission from Missy Berggren at The Marketing Mama.  The questions and answers provided in this article are geared primarily toward women in the United States and are not intended to provide complete answers for women in low-resource settings. 

Sally Wendkos Olds literally wrote the book on breastfeeding — The Complete Book of Breastfeeding that is. It’s newly revised and full of solid info for breastfeeding moms. Today Sally is joined by Laura Marks, MD, a pediatrician who co-wrote the book, to serve as our experts for the Expert Q&A series. Thanks Sally and Laura!

Here are the questions submitted by readers here on the blog, via facebook and e-mail, followed by Sally and Laura’s answers:

Why am I hearing it’s bad to use a used breast pump? Is it really bad if you get new tubes, filters and everything else? Hospitals and rental places let multiple people do it all the time, as long as each person has new tubes and holders.

The only type of pump that can be used by more than one woman is the kind designed with special barriers to prevent contamination from one user to another. Hospital-grade electric pumps have this, as do a few commercial pumps. Hygeia II states that its piston-driven personal-use electric pump has been FDA-cleared for use by more than one mother, each of whom needs to have her own accessory kit, the only part of the pump that touches her body or breast milk.

Is there anything I can do/use to prep myself for breastfeeding before birth?

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You don’t have to do anything during pregnancy to prepare your breasts for nursing, unless you have inverted nipples, in which case you may want to wear special plastic breast shells. These shells, also known as shields or milk cups, exert a constant gentle and painless pressure that gradually draws out a flat or inverted nipple. You can find them through your childbirth or breastfeeding education organization, through a catalog, or online. They are different from the rubbery nipple shields that are sometimes advised for sore nipples, but which should not be used. Women with inverted nipples used to be advised to do exercises during pregnancy, but this is no longer recommended.

Do supplements/teas/vitamins work to increase breastfeeding supply? If so, which ones? Any other ways to up supply besides actually nursing more often?

There’s no hard evidence that supplements, teas, or vitamins help to increase a mom’s milk supply, but many women swear by specific preparations. Most of them can’t hurt, but if you’re thinking of using herbal tea, stick to reliable brands and drink in moderation. Just because something is natural doesn’t mean that it’s safe. Always check with your doctor before using anything. Meanwhile, remember that the best way to increase your milk supply is to keep removing milk from your breasts, primarily from frequent breastfeeding, and also from pumping.

When do you quit trying to breastfeed? I was told to stop at 2 weeks and go to pumping only so that we knew how much my daughter was really getting due to failure to thrive. I think now that if I had stayed with direct versus pumping I may have had success and that my milk was just late to come in, but the inefficiencies of a pump over an actual baby stalled it. But obviously, at some point you have to admit that it really isn’t going to work for some reason. How do you know where that point is, and when to keep pushing?

Even if you have to give your baby supplements of formula to help her gain weight, you should continue nursing as often as you can for the first couple of months. Even the best breast pump is not as efficient as a vigorously suckling baby in stimulating the breasts and thus increasing milk supply. Current recommendations include giving the supplement first so the baby is not so wildly hungry and will be more likely to nurse.

How is it possible that I can breastfeed my 15-month-old only once a day, when before I would get too engorged to go that long between feedings?

Breastfeeding is the ultimate example of supply meeting demand. As your breastfeeding schedule changes with your baby’s development, your breasts adapt. Your 15-month-old is now eating solid foods and not needing as large a supply of milk, so your breasts respond by producing less milk.

What changes will happen to my body when I completely wean my baby? Will my weight be affected? Will my hormone levels shift? Also–how might my weight be affected when I stop nursing? I know I won’t be using as many calories, but are there also hormonal changes that may affect my weight when I stop nursing?

When you stop breastfeeding, your body will undergo a number of physiological changes as your hormonal balance reverts to what it was before you became pregnant. As soon as you added foods other than breast milk to your child’s diet, it became easier for you to become pregnant again. If you have not already adopted a method of birth control and if you don’t want to conceive right away, you’ll now need to use some means of contraception.

The most obvious change will be in your breasts. It may take several months for you to lose the bulk of your milk, even though none may be apparent within days after the last nursing session. Some women are able to express a drop or two of milk from their breasts up to several years after weaning. Nipple stimulation promotes milk production, so if you’re always checking for milk, you’re likely to find some. Also, consistent nipple stimulation during sexual activity can result in slight milk secretion for some time.

It may take several months for your breasts to return to their former size. They’ll most likely be less firm than they were before you became pregnant, but this is the result of childbearing, not breastfeeding. They’ll probably seem to be the same size they were before your pregnancy, although some women feel that their breasts become larger or smaller after nursing. This may have something to do with the amount of weight gained or lost or with their having become accustomed to having larger breasts.

Breastfeeding can help a mom return more quickly to her pre-pregnancy size. There’s some evidence that nursing helps women to regain their figures, since the fat stores developed during pregnancy are laid down specifically for lactation. Women who don’t nurse may have a harder time working off this fat. Just think of it—you’re burning about 500 calories a day through lactation, as many calories as you’d burn on a five-mile run. Some women do retain a few pounds of extra weight while they’re nursing, which they often lose after weaning without doing anything special. Other women find that after weaning they need to cut back on calories and embark on an exercise program to lose this weight.

My daughter is starting to eat more at night and less during the day (reverse cycling), how do I get her to stop? I’m a stay-at-home-mom, so I would prefer she eats during the day when I’m awake rather than 2-3 times at night. Any hints?

She needs to learn the difference between night and day! You can help her by keeping lights on and noise present (maybe from a TV or radio) during the day. You can also wake her at intervals that correspond to her present night-schedule. Also, taking her out in the fresh air and sunlight should help.

Are there official recommendations for mothers who have cesareans or who have premature babies, including micro premies? I know the idea is that breast milk is best, but many moms are separated from their babies and/or they are told that formula is better for their babies. What suggestions do you have for these mothers, especially about feeding at the time of birth and during the hospital stay.

Mothers who have cesarean deliveries can start to nurse as soon as those who have vaginal deliveries. You’ll have to make special efforts not to put pressure on your incision, but otherwise the process is about the same. For moms who deliver prematurely the situation is different, depending on the size and health of the baby. If the baby cannot nurse right away, you can pump your milk and either supply it to the hospital or freeze it for later use. Prematurity is temporary, but breastfeeding can continue for many months.

Procedures for feeding a baby born before term vary, depending on the infant’s size, gestational age, strength, and special needs. Your baby may be technically classified as preterm, but be well formed and strong and lack only a few ounces to be considered of normal weight. In this case, you can probably start to nurse immediately.

Very tiny infants, however, are often not able to suck; they may have to be fed by gavage (via a tube that goes from the nose into the stomach) for several weeks until they become strong enough to nurse. Ideally, the doctor in your hospital’s preterm unit will graduate your baby directly from gavage to breast. In the United States this often happens when an infant reaches a weight between three and four pounds. Some hospitals, however, still require preterm babies to suck first from a bottle to demonstrate their ability to feed; only when they’re taking a bottle at every feeding are they permitted to nurse at the breast.

Because of the protective factors in breast milk, it is best for preterm babies too – if the mother can produce enough milk, either to nurse her baby directly or to pump milk that will be fed by bottle or gavage. Very small preterm infants, however, who are receiving pumped breast milk may need more nutrients than the mother’s milk can provide. These babies often receive a supplement added to breast milk called human milk fortifier (HMF), which is rich in calcium and protein. Your doctor may want your baby to continue to receive extra calcium and protein along with your breast milk for some months after discharge from the hospital. Since HMF is not available outside of hospitals, these nutrients may come from specially fortified formula given in addition to breast milk.

The milk of women who bear preterm babies differs from the milk produced by women who deliver at term. Mothers of preterm babies produce milk specifically designed for their own babies at the infants’ stage of development.

Compared to the milk of a mother of a full-term baby, the milk of a mother of a preterm baby is easier to digest and better constituted for developing the preterm baby’s brain and nervous system. Milk from mothers of preemies has higher levels of nitrogen, protein, sodium, and chloride than full-term milk, and lower lactose content than full-term milk. It provides more energy for the preterm infant’s growth needs than mature milk. It also has a high level of lipase, an enzyme that aids in fat digestion.

Can a mother switch to exclusive breastfeeding (if she wants to) if a premie was given formula or bottles in the early days?

Yes. If she has kept up her milk supply by pumping, she should be able to provide whatever her baby needs once the baby is strong enough to nurse.

I heard recently that formula is now as good as breast milk, is this true? Can it ever really be done?

Formula will never be as good as breast milk for human babies. The milk of every species of mammal is different in composition from every other milk, and formula is typically based on milk from cows. Furthermore, each mother’s milk is custom-designed for her own baby: Women develop specific antibodies against bacteria and viruses in their own lungs and intestines, which also appear in their milk. Breast milk changes in composition from feeding to feeding, from day to day, and from month to month, whereas formula remains the same at every feeding.
Human milk contains at least one hundred ingredients that are not in cow’s milk, and while artificial formulas try to imitate mother’s milk, they can never duplicate it exactly. No manufacturer has ever officially claimed that a formula product is just as good as or better than breast milk, and none is likely to make such an audacious claim. In fact, the Food Standards Agency in Great Britain plans to bar infant formula makers from making claims that their products are close to breast milk. As one team of researchers wrote, “Formula milk is just a food, whereas breast milk is a complex living nutritional fluid that contains antibodies, enzymes, and hormones, all of which have health benefits.”

We’re constantly discovering new ingredients in mother’s milk. With breast milk, the whole is greater than the sum of its parts. We don’t know all the constituents in breast milk and how they work together.

My first baby refused to take a bottle. I was a stay at home mom and was happy to breastfeed, but felt completely confined because I could not leave my husband home with a bottle of breast milk. Do you have any tips on how to get a baby to drink from a bottle when they are primarily breast fed?

The solution is to start offering a bottle early – after the course of breastfeeding is well established, but before the baby makes up her mind that the bottle is not for her. This window of opportunity generally comes up between 6 and 8 weeks of age. If a baby is older than this when you want to introduce the bottle, there are a few ways to overcome the baby’s refusal of the bottle: warm the nipple and milk to body temperature, ask someone else to pick up the baby when he’s sleeping but almost ready to wake so that his instinctual urge to suck takes hold, and experiment with different feeding positions.

If I drink a glass of wine, how long before it gets into the breast milk? Is it best to “pump and dump” when I plan on having a drink? What about four drinks?

What the mom takes in usually reaches the breast milk in a few hours. The best scheduling involves having your glass of wine soon after a feeding. Having four drinks within a short period of time can be considered “binge drinking,” and not only would it be dangerous for a baby to nurse after the mother’s having drunk that amount, it’s not healthy for the mom either. As with so much in life, moderation is the key. While you’re nursing it’s best to be extra-moderate.

Is there a best age for weaning?

The American Academy of Pediatrics recommends nursing for at least a year and as long thereafter as mother and child want to continue. Both the World Health Organization and UNICEF recommend breastfeeding for at least two years. However, even if you cannot or do not want to nurse for many months, whatever breastfeeding you do offer your baby will go far to provide a good start in life.

During the first couple of days after birth, infants get the immunological advantages of colostrum, and they continue to receive immunological benefits from breast milk at least through the toddler years. During about the first six months, babies can usually satisfy all their nutritional needs from breast milk; at some time after this the combination of breast milk and various other foods will provide their essential nutrients. By nine months they usually have enough teeth and the intestinal maturity to handle a wide variety of foods. They are still, of course, dependent on their parents for many of the essentials of life, but from a nutritional aspect, they need no longer be dependent solely on their mothers’ milk.

The emotional benefits that a mother and child derive from breastfeeding are just as valid, however, at two months, six months, nine months, one year, or later. If you want to continue nursing for emotional reasons rather than nutritional ones, there’s no need to stop at any specified time.

But what if you decide, for one reason or another, to stop nursing before six months? Even if you have nursed only a few weeks and you have to, or want to, stop breastfeeding, you are still a successful nursing mother. You have given your baby a good start in life and you yourself have known the special joy of the nursing relationship. Any breastfeeding is better than none at all.

Sally Wendkos Olds has written extensively about breastfeeding in the Complete Book of Breastfeeding (Become a fan on facebook!), relationships, health and personal growth. She also wrote The Working Parent’s Survival Guide, Super Granny: Great Stuff to Do with Your Grandkids, among others, and writes a fun blog called Super Granny: How today’s grandmothers have fun with, relate to, and communicate with our grandchildren.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

 

Tell us your story. Have religious restrictions affected your ability to access health care? Email stories@rewire.news

Commentary Sexuality

Black Trans Liberation Tuesday Must Become an Annual Observance

Raquel Willis

As long as trans people—many of them Black trans women—continue to be murdered, there will be a need to commemorate their lives, work to prevent more deaths, and uplift Black trans activism.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

This week marks one year since Black transgender activists in the United States organized Black Trans Liberation Tuesday. Held on Tuesday, August 25, the national day of action publicized Black trans experiences and memorialized 18 trans women, predominantly trans women of color, who had been murdered by this time last year.

In conjunction with the Black Lives Matter network, the effort built upon an earlier Trans Liberation Tuesday observance created by Bay Area organizations TGI Justice Project and Taja’s Coalition to recognize the fatal stabbing of 36-year-old trans Latina woman Taja DeJesus in February 2015.

Black Trans Liberation Tuesday should become an annual observance because transphobic violence and discrimination aren’t going to dissipate with one-off occurrences. I propose that Black Trans Liberation Tuesday fall on the fourth Tuesday of August to coincide with the first observance and also the August 24 birthday of the late Black trans activist Marsha P. Johnson.

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There is a continuing need to pay specific attention to Black transgender issues, and the larger Black community must be pushed to stand in solidarity with us. Last year, Black trans activists, the Black Lives Matter network, and GetEQUAL collaborated on a blueprint of what collective support looks like, discussions that led to Black Trans Liberation Tuesday.

“Patrisse Cullors [a co-founder of Black Lives Matter] had been in talks on ways to support Black trans women who had been organizing around various murders,” said Black Lives Matter Organizing Coordinator Elle Hearns of Washington, D.C. “At that time, Black trans folks had been experiencing erasure from the movement and a lack of support from cis people that we’d been in solidarity with who hadn’t reciprocated that support.”

This erasure speaks to a long history of Black LGBTQ activism going underrecognized in both the civil rights and early LGBTQ liberation movements. Many civil rights leaders bought into the idea that influential Black gay activist Bayard Rustin was unfit to be a leader simply because he had relationships with men, though he organized the 1963 March on Washington for Jobs and Freedom. Johnson, who is often credited with kicking off the 1969 Stonewall riots with other trans and gender-nonconforming people of color, fought tirelessly for LGBTQ rights. She and other trans activists of color lived in poverty and danger (Johnson was found dead under suspicious circumstances in July 1992), while the white mainstream gay elite were able to demand acceptance from society. Just last year, Stonewall, a movie chronicling the riots, was released with a whitewashed retelling that centered a white, cisgender gay male protagonist.

The Black Lives Matter network has made an intentional effort to avoid the pitfalls of those earlier movements.

“Our movement has been intersectional in ways that help all people gain liberation whether they see it or not. It became a major element of the network vision and how it was seeing itself in the Black liberation movement,” Hearns said. “There was no way to discuss police brutality without discussing structural violence affecting Black lives, in general”—and that includes Black trans lives.

Despite a greater mainstream visibility for LGBTQ issues in general, Black LGBTQ issues have not taken the forefront in Black freedom struggles. When a Black cisgender heterosexual man is killed, his name trends on social media feeds and is in the headlines, but Black trans women don’t see the same importance placed on their lives.

According to a 2015 report by the Anti-Violence Project, a group dedicated to ending anti-LGBTQ and HIV-affected community violence, trans women of color account for 54 percent of all anti-LGBTQ homicides. Despite increased awareness, with at least 20 transgender people murdered since the beginning of this year, it seems things haven’t really changed at all since Black Trans Liberation Tuesday.

“There are many issues at hand when talking about Black trans issues, particularly in the South. There’s a lack of infrastructure and support in the nonprofit sector, but also within health care and other systems. Staffs at LGBTQ organizations are underfunded when it comes to explicitly reaching the trans community,” said Micky Bradford, the Atlanta-based regional organizer for TLC@SONG. “The space between towns can harbor isolation from each other, making it more difficult to build up community organizing, coalitions, and culture.”

The marginalization that Black trans people face comes from both the broader society and the Black community. Fighting white supremacy is a full-time job, and some activists within the Black Lives Matter movement see homophobia and transphobia as muddying the fight for Black liberation.

“I think we have a very special relationship with gender and gender violence to all Black people,” said Aaryn Lang, a New York City-based Black trans activist. “There’s a special type of trauma that Black people inflict on Black trans people because of how strict the box of gender and space of gender expression has been to move in for Black people. In the future of the movement, I see more people trusting that trans folks have a vision that’s as diverse as blackness is.”

But even within that diversity, Black trans people are often overlooked in movement spaces due to anti-Blackness in mainstream LGBTQ circles and transphobia in Black circles. Further, many Black trans people aren’t in the position to put energy into movement work because they are simply trying to survive and find basic resources. This can create a disconnect between various sections of the Black trans community.

Janetta Johnson, executive director of TGI Justice Project in San Francisco, thinks the solution is twofold: increased Black trans involvement and leadership in activism spaces, and more facilitated conversations between Black cis and trans people.

“I think a certain part of the transgender community kind of blocks all of this stuff out. We are saying we need you to come through this process and see how we can create strength in numbers. We need to bring in other trans people not involved in the movement,” she said. “We need to create a space where we can share views and strategies and experiences.”

Those conversations must be an ongoing process until the killings of Black trans women like Rae’Lynn Thomas, Dee Whigham, and Skye Mockabee stop.

“As we commemorate this year, we remember who and why we organized Black Trans Liberation Tuesday last year. It’s important we realize that Black trans lives are still being affected in ways that everyday people don’t realize,” Hearns said. “We must understand why movements exist and why people take extreme action to continuously interrupt the system that will gladly forget them.”

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