Expert: Sally Wendkos Olds - 6/26/2009

Question
Hello,

My baby is almost 5 mos.  He was exclusively breasted until 3 MOS and then I returned to work.  I nurse him in the morning at 6 am then I pump right after that, I also pump 3 times at work while away from him.  I am home for his PM and PM feedings but he refuses the breast during those hours so I pump and he takes formula.  I pump a total of 6 times per day but only get 15 oz total from 6 pumpings which covers only 3 feedings a day.  He sometimes wakes up during the night (rarely) and breastfeeds.  My supply is dropping dramatically, so my question is if there is anything I can do to maintain it or increase it?  The baby refuses to nurse and there is no way I can squeeze another pumping I already pump every 3 hours while I am awake.  I cannot pump during the night as I have a very demanding job I need some sleep.

Answer
Dear Anna,

First, congratulations for giving your baby the best start in life by breastfeeding him! I'm sorry to hear of the problems you're having now, and I agree that you do need your sleep at night. Since it seems that your milk production is dropping (partly no doubt because your baby is not nursing as much), I'm attaching an excerpt of my book (see below) which offers suggestions for building your milk supply. I am also attaching an excerpt that gives suggestions for luring a baby back to the breast when he refuses to nurse.

Good luck!

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
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Ways to Build Up Your Milk Production
New mothers sometimes fear that they won’t have enough milk to feed their babies. They hear stories about other women who “didn’t have enough milk,” and they worry that they might be in this category. But when you look closely at the situations of these other women, the problem can almost always be ascribed to lack of information, lack of encouragement, or faulty nursing technique by either mother or baby. You need to tell yourself that millions of other women nurse their babies, and you can, too. Following one or more of the suggestions below should increase your milk supply within a few days.
• Nurse your baby more frequently for several days, using both breasts at each feeding. This is the single best way to enhance your milk supply.
• Wake your baby, if necessary, to feed him more often -- about every two to three hours during the day and at four-hour intervals during the night.
* Pump or express milk between feedings. But don’t get discouraged if your pumping yields as little as half an ounce of breast milk. Your baby is almost certainly getting more than this. Even the best pump is less effective than a vigorously nursing baby. (More about pumping in Chapters 16 and 17.)
• See a lactation specialist if your baby is not suckling well or nurses only a few minutes at a time.
• Cut back on your schedule. Do less. Rest more. Nap at least once a day, more often if you can manage it. Or at least put your feet up. Ask someone else to help with marketing, cooking simple meals (or getting take-out food), and doing basic laundry. Most people like to help a new mother, so take advantage of this willingness now. You can always reciprocate later on. Although people often want to help, they may not know just what you need. It may help to post a running To-Do list on your refrigerator for all to see.
* Even though everyone wants to see the new baby, ask visitors not to come for several days -- or even weeks -- unless they’re people who will wait on you, not expect you to entertain them. Let your answering machine take phone calls – which you can return later when you’re not so tired. Well-meaning family and friends can wear out the new mom.
• If you can, in the early weeks take an occasional day or two off from work or from other obligations (by, for example, having someone come in to care for your other children) so that you can focus only on nursing your baby.
• Check your diet. Are you eating enough? Are you drinking enough? Some women find that eating or drinking more seems to produce more milk. Keeping a glass of water or juice near the spot where you nurse is a good idea. You don’t need to drink any more than you need to meet your thirst, but some nursing moms find that they are thirstier than usual.
• Make a special effort to relax, as suggested in the box on page tk. Of course, this is hard when you’re concerned that your baby isn’t getting enough milk—but the more you can relax, the more milk your baby is likely to receive.
• Develop a few affirmations that you can repeat to yourself, such as: “I am a bounteous supplier of milk for my baby”; “I am doing the best thing I can as a mother”; “My baby is growing fit and healthy from my milk”; “My milk is my baby’s perfect food.”
* Visualize your baby at a little older age, looking well fed and  happy.
* Galactogogues: Virtually every culture in the world has recommended certain foods or substances to nursing mothers, in the belief that they help to make milk. In China, nursing mothers have been urged to eat “a mixture of pork fat and red gram (a type of bean), cuttlefish soup, shrimps’ heads in wine, and a special sweet wine made from glutinous rice, given together with the larvae of the blow-fly.” In India, it’s garlic, tamarind, and cottonseed; in France, powdered fennel; and in Nepal, chicken soup, buffalo milk, butter, and rice. In the U.S. vitamin B complex, brewer’s yeast, and the herbs fenugreek (also called fenugeek) and blessed thistle are sometimes recommended, as is the controversial prescription drug domperidone, which has not been approved for any use by the U.S. Food and Drug Administration. (See Chapter 10 and the Websites Appendix for more about drugs and lactation.)
  Cheston M. Berlin, Jr., M.D., a professor of pediatrics and pharmacology who has an interest in drugs and lactation, has concluded that the effects of such potions may be largely psychological. The mother thinks that a certain substance will increase her milk supply, so she relaxes and has a good let-down reflex, thus “proving” its value.
As we have stated, though, the best way to build up your milk supply isn’t what you eat. It’s what—and how much—and how often—your baby eats. The cutting edge research of Dr. Peter E. Hartmann’s Australian team (discussed in Chapter 3) has  confirmed what many breastfeeding experts have known for years: that emptying the breast is the best stimulus to milk production. The more often you nurse your baby and the more vigorously she nurses, the more milk you’re likely to have.
• Believe in yourself and trust your body.
Note: Do not offer your baby formula while you’re building up your milk supply. A few ounces soon turn into a full bottle, which soon turns into several bottles, until you find that you’re producing even less milk. If your baby is drinking from a bottle, he is not stimulating your breasts and thus not doing the most effective thing that will increase your supply of milk. In most cases, a breastfed baby should not be offered a bottle until nursing is well established—usually at about four to six weeks of age.
  The only exception to this is if your baby’s doctor (not your friends or relatives!) feels that he absolutely needs a supplement. Your doctor may be worried if your baby is sick, dehydrated, so small that his health is endangered, or if he is not gaining enough weight. Any one of these conditions may leave him without enough energy to nurse vigorously and thereby stimulate your milk production.
If a decision is made to supplement with formula, you might try offering a couple of ounces of formula in the bottle first before nursing him. This practice, which reverses previous guidelines for supplementation in the order of breast-followed-by-supplement, has become more widely recommended in recent years. This reversal of the usual feeding order satisfies the baby’s immediate hunger and gives him the nourishment he needs, but provides that he will get his final sense of fullness from breast milk, and associate this good feeling with his mother.
Some babies do better getting their supplement like this, while others thrive more on the traditional practice, of nursing first and supplementing afterwards. It’s not always clear which way will work best, so this is something you should discuss with your lactation consultant.
Another way of supplementing is to use a nursing supplementer, a device that lets your baby suckle at your breast (thus stimulating your milk production) while at the same time receiving formula (see page 000 for a description).
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The Older Nursing Baby Who Refuses the Breast
Sometimes in the first few weeks after birth, but more often between four and ten months of age, a baby will nurse a couple of minutes, then arch his back and cry. Nothing the mother can do will induce him to go back, and yet it’s obvious that he wants something. What’s wrong? And what can you do about it? As with so many other child-rearing issues, you have to look closely at your own baby and see what is going on in his life. The following suggestions have worked in some situations, and the box below lists several possible causes, along with some specific solutions.
• If you want to continue nursing, don’t substitute bottle-feeding for the times you would ordinarily nurse. Doing that may make the problem worse. Chances are that this “nursing strike” may last only a day or two, and your baby will then go back to being an eager nurser.
• If your baby has begun to eat solid foods, increase her portions of these for a few days to tide her over. Also, add some of your pumped breast milk to her cereal. If she has been eating large amounts of solids, however, this may be causing the problem. She may be too full of food to be interested in nursing.
• Express or pump your milk and give it to him until he resumes taking the breast.
• Keep offering your breast. The most effective time to do this is to pick him up while he’s asleep or very sleepy; he won’t remember to reject the breast, and once he’s back in the routine of nursing, he may decide it’s pretty good, after all.
• Vary your nursing positions. Your baby might prefer one you haven’t used yet.
• Nurse in motion—in a rocking chair or walking around.
* Give your baby a bottle with just a small amount of milk (ideally your pumped breast milk) first -- and then put her to the breast.
* Consider the possibility that your baby may be suffering from GER (gastroesophageal reflux), especially if he shows symptoms like arching his back or pulling away from the breast after starting to nurse. See the discussion of GER on page tk.
  If none of the possible reasons listed in the box on page tk to explain why your baby might be refusing your breast seem to apply to your situation, if none of the suggested remedies work, if after a couple of weeks she’s still refusing to nurse, and if she’s more than six months old, you can pump your milk and feed it in a cup or a bottle. You may also want to contact a lactation consultant to try to persuade the baby to continue nursing a while longer. While some children want to nurse long after their mothers had thought they would, others surprise and disappoint a mom by wanting to give up the breast earlier than she wants to herself. For suggestions to make the weaning process as comfortable as possible, with the least amount of emotional upset for mother and baby, see Chapter 18.

BOX
When an Older Baby Refuses the Breast
• Has your baby turned against the taste of your milk? It may have changed because of a cream you’re using on your breasts, a new food you’re eating, a new medicine you’re taking, a new strenuous exercise program you’ve begun, a developing infection in your breast, or because you’re pregnant or have just resumed menstruating.
Explore these possibilities, one by one. Keep a log of what you eat and what your baby’s reaction is, so that you can identify and eliminate an offending food. Schedule nursing sessions before exercise sessions. If you feel a lump in your breast, first treat it as a clogged duct; if it has not healed in three days, see your obstetrician.
• Is she teething? If her gums are tender from the pressure of new teeth coming in, it may hurt her to nurse. If she bit you, she may have been startled by your cry of pain and be afraid to nurse again. (See section about biting on page tk.)
• Is he wildly hungry? If he can’t seem to wait for the milk to let down, pick him up about fifteen minutes before you would ordinarily feed him, or express a little milk first to give your let-down a chance to work.
• Does she have a cold? She may be having trouble breathing through her nose. Use a humidifier in the room where she sleeps, ask your doctor whether nose drops would help, and use an aspirator (a syringe with a rubber bulb) to suction out mucus in her nose.
• Does he have thrush? This mouth infection, described earlier, can make nursing painful. If you suspect it, treat it immediately, both to relieve your baby and also since the infection can spread to you.
• Does she have an earache? If so, she may find nursing painful. Ask your doctor to evaluate her.
* Look at his symptoms and consider the possibility that he may be suffering from gastroesophageal reflux (GER – see page tk).
• Is your baby consistently refusing only one breast? If so, see your own doctor, since this may signal a medical problem that should be explored.
• Are you under tension? If you’re going through a particularly difficult time emotionally, your feelings may be coming across to your baby, who in turn becomes too upset to nurse. Make a conscious effort to forget about your cares, at least while you’re nursing. You’ll enjoy these oases in your life and your baby may be calmer, too. See the suggestions to help you relax in the box on page tk.
END BOX