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Wednesday, February 19, 2014

Solutions to the Challenging First Week of Breastfeeding

The first few weeks for any new parent is always the toughest.  For breastfeeding moms, these weeks are especially as this can make or break your breastfeeding relationship.  It is really important to surround yourself with breastfeeding supporters.  However, it is equally important to read and research and equip yourself with the information to help you succeed.

I realize that even if the internet is now easily accessible there is so much information out there, such that some new parents get overwhelmed and give up.  Plus, there are also information that come from dubious sources.  So, I decided to compile information which I believe in and find reliable in hopes that new parents can use this guide to gain confidence during the early weeks of breastfeeding their baby.

First concern of the mother is always whether she has milk.  Humans are mammals and one of the things that makes mammals different from other species is that we make milk.  There are certain instances when women cannot make milk and I wrote about that here.  However, it is important to emphasize that lactation failure must be diagnosed and not just based on feelings or beliefs.

The reason I always hear from moms why they supplement with formula or donated breastmilk during the first few days is because their "milk has not come in". I will repeat: YOU HAVE MILK FROM DAY 0 and that is colostrum. Colostrum is not the white gushing milk but it is enough to fill your newborn's stomach.  Let me share with you these visuals on the size of a newborn's tummy.
Photography by Stanley Ong
From Linda J. Smith

As you can see, a newborn's tummy is the size of a cherry or a shooter marble.  The tummy holds 5-7ml. Why so little?  Because the newborn's stomach is very small and the colostrum you produce is sufficient to fill this teeny-tiny stomach.  Imagine if you had to force in 2 ounces of milk (as is the usual recommendation of milk being given) - then you are already expanding your newborn's stomach and predisposing your baby to obesity

Then why is my baby constantly crying? S/he is always crying even after I have just fed her.  Imagine being cocooned in a warm dark space and constantly hearing the beat of your mom's heart.  Then imagine being suddenly thrust in a cold, bright world - with a huge space where you cannot feel anyone close to you.  That is how your baby feels at birth.  

The 1st 3 months of your baby's life is what Dr. Harvey Karp calls as the 4th trimester.  This is also the time when baby always wants to be close to mom, to be held by mom.  As explained by Teresa Pitman (Dr. Jack Newman's business partner) in this article, according to a study published in 2009 by lactation consultant Fleur Bickford, breastfeeding is an impressive form of comfort and is made more difficult because we put arbitrary limits on it:
Bickford finds that many mothers who are concerned about nursing their baby for comfort worry this will spoil the baby and make him even more demanding as he grows up. She reassures the parents she talks to that this isn’t a concern. “Research shows that babies who are held a lot and frequently nursed actually go on to be outgoing and adventurous children. By responding to babies’ needs quickly, consistently and with love, we teach them that the world is a safe and wonderful place.” 
Of course, if your baby is constantly at the breast, is not gaining weight and doesn't look contented or satisfied, there may be a problem.  What must be checked?  Latch and position.  More often than not, mom has enough milk but baby's latch is incorrect such that baby cannot draw out sufficient milk.  So get in touch with breastfeeding counselors or IBCLCs to get help.

Along with comfort nursing, an oft-given but wrong advice received by new moms is -- top it up with formula.  Ahh.. the top-up trap! The loquacious lactator has this very lovely visual:
Topping up with formula milk is a vicious cycle which will end up with you having less milk and never being able to give up the artificial feeds.   My tip to new moms - always offer the other breast.  If baby is still not satisfied, offer the other breast again.  Switch both breasts even if you do it successively.

Milk production is dependent on the law of supply and demand.  You must make your body think that it needs to make milk.  If you give your baby a bottle, that bottle replaces an opportunity for your baby to suckle at your breast signalling your body to make milk.  Remember - an empty breast makes milk faster than a full breast.   You do not have to wait until you feel full before you can feed your baby.  Your baby CAN get milk from your breasts, even if you feel that they are "empty."

But is it ok for me to give just one bottle of formula or donated breastmilk so I can sleep?  Two words - virgin gut.  I first heard of this term from this article by IBCLC Marsha Walker - "Just One Bottle Won't Hurt" or Will It?.  As explained in that paper, the gastrointestinal tract of babies are immature at birth and take weeks to mature and close.  See comparison below from The Alpha Parent:
While the gut is immature, there is a high risk of acquisition of NEC (necrotising enterocolitis or destruction of the bowel), diarrhoea and allergies.  However, breastmilk obtains sIgA which coats the gut and provides protection during its immaturity.  As explained in this 2014 article, while humans can make sIgA, in the earliest days of life, mother's milk is the only source of this antibody.

Walker's paper cites several references which state that even small amounts of formula supplementation (1 supplement per 24 hours) will result in changes of the gut from breastfed to a formula-fed gut flora pattern.   Babies with formula-fed gut flora pattern have higher risks of developing allergies, insulin dependent diabetes mellitus, inflammatory bowel disease, etc. etc.  Walker further explains that even if the baby will be exclusively breastfed again, it will take 2-4 weeks for the gut flora pattern to go back to that of a breastfed baby's.

There is also another reason why babies seem to sleep longer if they are given artificial milk.  Most artificial milk is made of cow's milk.  A calf has 4 stomachs while humans have 1.  This means that the protein content of cow's milk is higher because the milk goes through 4 stomachs before being fully digested.  Meanwhile, your baby's 1 stomach has to work harder to digest the protein - and this is the reason why baby is asleep longer.  Yes, baby may be sleeping longer BUT you are also taxing your baby's body.

Thus... that one bottle?  I wouldn't recommend it.

To keep yourself going during those early weeks, I encourage new parents to learn how to baby wear. Babywearing has been very helpful to me and many other mothers especially during the first few weeks of navigating baby's temperament and routines.  This was especially helpful during E's first month when we had no helper and had to take care of 1 child each.

Learn how to breastfeed in a side-lying position.  This is very helpful especially for night nursing sessions.   Take everything in stride and do not attempt to do everything.  Some messes will be left lying around, you won't be able to spend as much time with your other kids or partner.  And it is ok -- this will be temporary.

Surround yourself with like minded people.  Connect with breastfeeding friends, support groups and reading materials.  Take care of yourself and remember -- take breastfeeding one day at a time -- or even one feed at a time.  While breastfeeding is natural, it is a learned skill.  Give yourself and your baby time to learn and adjust to each other.  It will get easier!

Update  4 March 2014:
In this article by Nancy Mohrbacher, she emphasizes that aside from diaper output, there are be other factors that must be considered in evaluating milk intake:
So at best, diaper output can be considered a rough indicator of milk intake. While it can be helpful to track diaper output on a daily basis between regular checkups, diaper output alone cannot substitute for an accurate weight check. Other indicators of good milk intake, such as alertness, responsiveness, and growth in length and head circumference. 

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