An OB Shares Her Patient's Questions About Breastfeeding

by Michele Brown, OB/GYN

Here's What You'll Find Below:  • Common pumping problems
  • Increasing your milk supply
  • Plugged ducts
  • Latching baby
  • Weaning to bottles

newborn at the breastAs an OB, my patients ask me just as many questions about breastfeeding as they ask about pregnancy itself. I don't mind at all because it is such an important topic. Over the years, I have scribbled many of these questions in my notebook so that I could research the most current information for new mothers eager to learn how to feed their babies the natural way.

Before writing this article, I interviewed the head lactation consultant, Ms. Renate Abstoss at Stamford Hospital in Connecticut, to get a second opinion and gather her responses. Ms. Abstoss sat for the First International Board Exam for Lactation Consultants in 1985 and has continuously worked in the field since that time in California, New York, Germany, Austria, Switzerland, and Connecticut. She was the first lactation consultant appointed as State Certified Teacher for Bavarian Midwifery schools.

There are probably many variations of responses to these questions so please consider this information helpful, but not absolute. I welcome any additional "pearls" from other lactation consultants or experienced moms so we can share the knowledge and promote the best nutritional health for babies everywhere.

What Are the Most Common Problems Women Encounter When Pumping?

Dwindling milk supply is probably the foremost problem that women encounter when pumping milk. This can be attributed to many different factors:

  • Infrequent pumping: A working woman should try and pump every 3 hours for 10 to 15 minutes or at least for every missed feeding.
  • Inefficient pumping: Pump being used may have inadequate pressure or not enough cycles per minute causing a decrease in the milk supply.
  • Lack of time at the breast: When mom is home from work, she should try and breast feed the baby to stimulate milk production. For convenience, babies may be bottle fed too frequently.
  • Painful nipples: This can be due to a bad pump due to excessive suction pressure, pumping for too long a period of time, or poor latch when the baby does breast feed.
  • Fatigue and exhaustion: The stress of taking care of a newborn along with pressure from work and home can result in exhaustion and fatigue which can decrease the milk supply.

How Do I Increase My Milk Supply?

There are several medications and herbal products available to help with increasing the milk supply. To increase an existing milk supply, one can take two herbal supplements in combination -- fenugreek and blessed thistle, both of which are available in health food stores and have no known contraindications.

The prescription drugs Metoclopramide and Domperidone, both of which were designed as stomach medications, increase prolactin production in the brain. The medication Domperidone, (Motlium) is not approved for use in the United States and the FDA has issued warnings against the use of this drug as a galactagogue because in higher dosages, when given intravenously, Domperidooe it was associated with cardiac arrhythmias and cardiac arrest.

However, the small dosages that are used when given orally to increase lactation (30–40 mg/day) and for the short duration of three to six weeks does not seem to be a great concern. Patients generally obtain this medication from Canadian pharmacies or from Mexico and Europe where it is over the counter. Studies are now being conducted by ILCA (International Lactation Consultant Association) regarding the safety of domperidone.

Metoclopramide (commonly known as Reglan), used to treat severe nausea in pregnancy, has been known to have a side effect of depression so its use has to be carefully monitored in the postpartum mother. The drug can be detected in breast milk and the long term side effects to infants is unknown.

How Do I Treat Plugged Milk Ducts?

Milk ducts that do not drain can cause the milk to back up resulting in a plugged milk duct. Often the the surrounding breast tissue becomes hardened and inflamed. This area can eventually become infected resulting in a mastitis requiring antibiotic therapy. Plugged ducts often occur when:

  • Mom misses feedings
  • Mom fails to pump frequently
  • The breast fails to empty
  • Nursing more frequently
  • Changing positioning

Improving the latch of the baby (sometimes a shield is necessary). A lactation consultant would be very instructive in this situation.

A plugged duct can be the result of incorrect positioning, inadequate pressure from a pump, or restriction of milk flow from poorly fitting bras or any kind of breast trauma that damages the duct. Fatigue, stress, or failure of the baby to latch on properly can also contribute to this problem.

Standard treatment consists of moist heat beforehand for approximately 5 minutes, empty breast as much as possible, cool compresses afterwards, and reduce swelling in between feedings. Massaging the duct towards the nipple may also be helpful.

If the plug comes out, it may look like dried milk in a string. One should continue to nurse to fully clear the plug. Apply cold compresses via an ice pack or a plastic bag of frozen peas for approximately 15 to 20 minutes.

Fresh cabbage leaves to the area is another herbal remedy that can be used in between feedings to help with engorgement. Cabbage leaves can be left in the bra for approximately one hour until it wilts. It is important to avoid the nipple area when applying the cabbage leaf because the cabbage is caustic and can cause irritation.

What Do I Do If the Baby Does Not Latch?

Latch problms can depend upon what situation you're experiencing. For example, you might be or have:

  • Is your newborn just learning how to latch? Assistance from a lactation consultant can be very helpful in making sure the baby is latched deeply with a mouth very wide to get all the breast tissue. The baby should be latched well beyond the tip of the nipple. Often latching problems occur because the baby fails to flare the bottom lip.

  • Is it due to flat or inverted nipples? If the problem is due to flat or inverted nipples, a suction device, pump, or nipple shield may be used to avoid engorgement by expressing the milk. This will avoid a lowered or disappearing milk supply. Different lactation consultants and hospitals may prefer one modality over another, however all agree that care has to be taken when using any device that serious trauma or damage does not occur to the nipple.

    Once the baby is "educated" that the breast is his or her "food supply," generally the baby will nurse fine. It is helpful to try and get beyond the first few days when only colostrum is present, until the milk comes in. Try and avoid avoid artificial nipples at the very beginning.

  • Is the baby not hungry at this time? If your baby is not hungry, he may dawdle and play instead of actively latching. The clock is not a good indication of hunger. Instead, watch your baby for signals such as moving head from side to side, opening mouth, sticking out tongue, mouthing hands and fists, puckering lips as if about to suck, nuzzling and rooting.

  • Is there a nursing strike? A "nursing strike" can occur if a well nursing baby, beyond the newborn period suddenly refuses to nurse. This can occur often after 4 months of age when a mother will state "my seven-month-old baby just suddenly weaned herself." These babies are not weaning but are actually facing a situation where nursing has become unpleasant, boring, or painful.

  • Often these infants need to be taught to return to a functional breastfeeding pattern with increased skin to skin contact, trying to nurse in a quiet, calm environment without distractions, such as nursing at night in bed. Bottles should be avoided but spoon or cup feeding with expressed milk is acceptable. If the underlying cause is treated, most babies will happily go back to their normal nursing pattern.
  • Is the baby getting sick? Causes of poor latch can be an undiagnosed ear infection, a urinary tract infection, or an upper respiratory infection. Check with your pediatrician to be sure an illness is not being missed. Maternal stress can also cause this problem.
    Regardless of the problem, it is important to remove the milk as efficiently as possible if an established supply exists to avoid engorgement which will lower or cause the milk supply to disappear.

    If the baby is not latching, it is important to stimulate the establishment of milk production through use of a pump.

How do I Decrease Supply After I Wean?

Weaning is the time the baby transitions away from the breast. Time frames for weaning can vary from weeks to months. Slow weaning is always more optimal. In this case you will drop the least sought-after feeding. A few weeks later you might substitute a meal for a feeding. Eventually your baby is weaned and your milk supply is minimal.

Some mothers will use the pump for weaning and stop breastfeeding entirely. One option for weaning would be to reduce the time per pumping, ie instead of pumping for 15 minutes, reduce it to 10 minutes. This can gradually be dropped down to 2 to 3 minutes per session.

An alternative way to wean is to increase the interval between pumping sessions, e.g. from every 3 hours to every 4, 6 or even 8 hours. If desired, one can use ice packs after pumping for comfort. Also, Motrin can be used for anti-inflammatory pain relief. A comfortable, tight bra can also help with support and relief. Nursing pads can be used to prevent excess leakage. A recommended herbal remedy can be drinking 3 cups of sage tea which is available in health food stores. It has a strong and astringent taste so adding honey makes it more palatable. Do not use this if currently pregnant since it has abortive action.

On occasion, sudden weaning becomes necessary. Discomfort is generally greater since the breast continues to make milk and the breast remains engorged. Nursing can be replaced with pumping but only pump the breast to allow comfort and not to completely drain. Increase time frame between pumpings.

Three days of Sudafed can help dry up the milk production. The milk supply decreases as you feed less. The milk quality also changes becoming more salty and colostrum-like which many babies do not like. Consequently, this also helps diminish the nursing.

Dr. Brown, founder of Beauté de Maman, is a board-certified member of the American College of Obstetrics and Gynecology, a member of the American Medical Association, the Fairfield County Medical Association, Yale Obstetrical and Gynecological Society and the Women's Medical Association of Fairfield County. She is a magna cum laude graduate of Tufts University, completed her medical training at George Washington University Medical Center and completed her internship and residency in obstetrics and gynecology at Yale-New Haven Hospital. Dr. Brown has a busy obstetrical practice in Stamford, Connecticut and, as a clinical attending, actively teaches residents from Stamford Hospital and medical students from Columbia Presbyterian Hospital in New York.

Copyright © Michele Brown. Permission to republish granted to Pregnancy.org, LLC.