Even Lactation Consultants Get Engorged

While pregnant with our seventh child this past fall, the thing I was most looking forward to about the birth was getting to nurse a baby again. When our older children were small, there was a period of about nine years where I was continuously either pregnant or nursing, and during this time I studied human lactation, and practiced being a lactation consultant, and ultimately achieved my goal of becoming an IBCLC. Baby #6 was 1 year old when I officially began my private practice. Our newest baby—she was born at the winter solstice, and her name is Edith—arrived after a gap of eight years, dozens (hundreds?) of lactation clients later. I was pretty sure going into her birth that I knew everything I'd need to know about nursing her. 

 
Edith Marta, one hour old.

Edith Marta, one hour old.

 

The second thing I noticed about my baby daughter after she was born, after her noticing her sex, was her tongue tie. This sounds kind of terrible in retrospect, but I assure you that this baby's tongue tie was no subtle thing. The nurse attending the delivery also happened to be an IBCLC, and she noted Edith's tongue straight away as well. We anticipated that our baby might arrive with some tethered oral tissue ("TOT" as it's called in the lactation world) due to family history, but I had certainly hoped for a different outcome. Despite her restricted tongue, baby Edith began nursing within minutes of her arrival; she did not struggle to attach. What a relief! And how fantastic to feel the sensation of a suckling baby once again, several years after weaning my next-youngest child. 

The "fantastic" sensation did not last long. It really hurts to nurse a tongue tied baby! By day two, my nipples were quite painful and raw on the faces, the way they often get to be when the nursling has a tongue tie. I saw so many of my clients in my mind's eye as I scrunched my eyes shut, and curled my toes, bracing against the sharp pain of Edith's mouth attaching to my nipples. We made an appointment to bring her to Dr. Shamey, a pediatric dentist and my preferred provider for the treatment of TOT, for a revision as soon as possible. 

In the meantime, we brought baby Edith home to her eager and adoring older siblings. Everyone wanted to hold her, of course, and my wife—Edith's other mother—and I had to fight for our own turns to snuggle with our newborn. On the evening of day 3, when I stood in my shower, attempting to massage my terribly engorged breasts, I realized that I had not been doing a great job of following my own advice. "Keep your baby skin to skin on YOUR chest, as much as possible in the first week," is one of my oft-referenced tips for the early days of nursing. Close and near-constant contact in the first week after birth can help your hormones and ensure that baby nurses as frequently as possible, helping to bring the milk in swiftly and reducing the incidence and severity of engorgement. It turns out that it's not easy to be your own lactation consultant! I had let my desire for the rest of the family to bond with the baby stand in the way of what would have likely been an easier transition for my body if I had kept baby Edith on me more of the time.

Though I've sent many, many newborns to ENTs and pediatric dentists for tongue releases over the years, bringing my own baby to see Dr. Shamey was not an easy move to make. I was glad for the opportunity to be on the other side of the experience, to have a taste of what it might feel like to my clients when they bring their babies for TOT revision, and at the same time, I felt tempted to back out of the appointment! Even knowing everything I know about the benefits of releasing a tongue tie, and the disadvantages of having a tongue tie, part of me still wanted to just leave Edith exactly as she was. I barely slept the night before the appointment. But in the morning, I knew we had to follow through with bringing her in. 

The procedure was quick, Dr. Shamey was especially loving and pleasant, and when Edith nursed immediately after, the only word I could think of to describe the sensation was "gentle." Within a couple of days, my nipples were completely healed, and my wife and I were becoming relatively proficient at doing the [dreaded] exercises to help prevent Edith's tongue from reattaching to the site where it had previously been tethered.

Edith is seven months old now, and nursing her has been smooth sailing since her tongue revision on day 5. Those first few days weren't easy, though, even for me as an IBCLC and experienced mother. The fresh reminder of how much it can hurt to nurse a new baby makes me want to shout from the rooftops about the importance of GETTING HELP when nursing is anything other than straightforward and pleasant. So: call me! :)

 
Edith and me, July 2018.

Edith and me, July 2018.

 

You say "hindmilk," I say "milk"

Lately, I've had a slew of clients who are all concerned about hindmilk (among other things), and I've been wanting to shed some light on this topic. For the most part, my response to someone who inquires about her "hindmilk" situation is, "please forget you ever heard that word, and don't worry about it."

What is hindmilk, exactly? It's really just a fancy word for milk. 

Many years ago, some lactation experts introduced the concepts of hindmilk (the "fattier" milk at that flows from the breast after baby has been suckling for a bit) and foremilk (the "watery" milk that flows from the breast at the start of a feed). And while it's true that slight variations in the fattiness of your milk do occur throughout the day and from the start of the feed to the end of the feed, this isn't really something that most women need to think (much less worry) about whatsoever. 

The scenario that most often comes up in my practice is that I'll be observing a nursing session with a new mom, and notice that baby is hanging out at the first breast, sucking, but no longer actively swallowing the way he/she was at the start of the feed.

And I'll ask the mom, "when do you usually decide to switch baby to the other side?" 
The most common response I'll get is, "well, I want to make sure baby gets alllllll the hindmilk."

A common refrain we hear these days in the lactation world is the advice to "finish the first breast first," before switching sides. Rather than look at a clock and decide to switch sides after some arbitrary number of minutes, the way nursing mothers were advised to do in recent history, mothers are now advised to let baby finish whatever side baby has started on before switching over. The reason to wait, they're told, is because of the hindmilk. 

While it is true that it's best to "finish the first breast first" the reason isn't so much that baby needs every lost drop of "fattier" hindmilk from the first breast as it is that it's best to empty the first breast before switching over ("empty" in this case just means that milk is no longer readily flowing; you will still be able to express some milk from an "empty" breast). The goal is to not leave large quantities of milk sitting in the breast at the end of the nursing session. Milk that sits in the breast for long periods of time is going to lose a bit of fat content before baby returns to the breast to feed again.

I love the analogy that Kelly from Kellymom uses to describe hindmilk and foremilk. She compares the human breast to a water faucet. Because I live in an old, New England, Victorian-era farmhouse, this analogy is quite relevant in my life, and hopefully you can relate to it to. Imagine what happens when you turn on the hot water in a second-story bathroom sink. For the first bit of time, the water that flows from the tap will be cold, while the hot water makes its way up the pipes from the basement. The hot water in this analogy is the hindmilk, and the cold water is the foremilk. If, after washing your hands in the finally-hot water, you turn off the tap for only a few minutes and then return to use the hot water again, you will usually find that the hot water runs quickly. You don't need to wait for it to come up from the basement because the water hasn't had time yet to cool in the pipes. Alternatively, if you leave the bathroom for several hours and then return to wash your hands again, the water that was once hot in the pipes will have cooled down again, and it will take a minute or so of letting the tap run before the water runs hot. 

It works in a very similar way with your milk. If baby nurses frequently from the same breast, the milk will remain relatively "fatty," just as the hot water flows relatively quickly from a tap that is frequently turned on. If milk sits in the breast for a couple of hours (or longer), it will lose some fat content with the passage of time, and the "foremilk" available at the start of the next feed will have lower fat content than the "hindmilk" did at the end of the previous feed. But baby can still get plenty of fat so long as baby drains the breast of milk at the next feed. And just like water in the tap—which tends not to go dramatically from cold to hot, but rather warms gradually as the water flows—the milk gradually increases in fat content as the feed goes on, depending on how quickly it is being removed from the breast. If the faucet is turned on full blast, the hot water will appear faster than if the faucet is only opened up to a trickle. Likewise, when baby nurses actively and eagerly, and removes milk quickly, the milk increases in fat content faster than when baby is being more lackadaisical (and perhaps is nursing less for hunger than for comfort). 

The best way to ensure that your baby is getting all the fattiest milk your body can make is to nurse frequently. The less time that elapses between feeds, the fattier your milk will be (to a point! There is, of course, a limit to how fatty human milk can be; it's a relatively low-fat milk when compared to the milk of other mammals). Nursing frequently is a much better way to ensure that baby gets plenty of fatty milk vs. keeping baby on one breast or another for an extended period of time. 

But when do you switch sides? How do you know when the first breast has been "finished"? Some babies will pop themselves right off of the breast when they've drained it as a way of telling you that they're ready for the other side. But many babies—especially newborn babies—will just keep right on sucking on the first breast, regardless of whether or not milk is continuing to flow. This is why it's important to learn to tell the differences between the various types of nursing and sucking that your baby does. A baby who is actively nursing is sucking relatively continuously (with occasional pauses to rest), and more importantly is swallowing very frequently. During active nursing, your baby will swallow after every suck or every couple of sucks. Once the flow of milk has slowed, baby's rate of sucking may also slow, and baby's rate of swallowing will definitely slow. You'll notice that baby is only swallowing intermittently, after several (10 or more) sucks, or may not be swallowing at all. This is a good moment to switch baby to the other breast, no matter how long baby has been nursing on the first breast for. You can return to the first breast (or "third" breast) after baby has finished swallowing on the second breast. 

Ironically, I've seen quite a few babies who weren't getting quite as much milk as they'd like because they were being restricted to nurse on one side, well beyond when they'd finished swallowing at that breast, due to their parents' concerns about hindmilk. This is why I mostly advise my clients to forget all about "hindmilk" and "foremilk" and think only of the liquid flowing from their breasts as milk

Why is nursing so difficult?

When I first became an IBCLC, my mother would not infrequently lament to me that she had no idea why such a profession even existed. "I nursed all three of my babies without any help at all," she boasted.

Well, that's nice for you, mom (and nice for me, too, since I was one of those babies!). Sometimes, nursing does come easily to new parents, even when they've had little exposure to nursing babies before. And I often hear flavors of my mother's sentiment echoed in others who—while they understand intimately that nursing IS in fact quite challenging—don't understand why nursing is so hard if it's truly what our bodies are "designed to do." In cultures around the world, the vast majority of mothers nurse their babies successfully (they often don't have a good alternative), and surely they're not all relying on lactation consultants to help them through the hurdles of the early weeks. Why is it that women in our culture struggle so much with something that should be so natural?

It's time to tell the gorilla story. The gorilla story is rather infamous among those in the U.S. lactation world, though oddly, it is very difficult to source (believe me, I tried!). In the 1980s in Ohio, a female gorilla in captivity gave birth to her first baby. Never having been around other mother gorillas and babies before, this new mother gorilla didn't have a clue as to how to care for her new infant. She did not know how to feed it, and the baby gorilla died. 

When the same mother gorilla became pregnant for a second time, the zoo tried to better prepare her for success; they called La Leche League. LLL is an international organization comprised largely of volunteers—actively nursing mothers, and mothers who have previously nursed their babies—who offer mother-to-mother support to nursing moms. In the gorilla story, nursing mothers from a local LLL group came each day to nurse their babies in front of the pregnant gorilla. At first, the gorilla wasn't terribly interested in the mothers, but as her due date approached, she seemed to be paying close attention to the nursing babies just outside of her enclosure. And when her second baby was born, she successfully nursed and cared for it, just as she had been watching the human mothers do throughout her pregnancy. 

Photo credit:  Clara S. 

Photo credit: Clara S. 

It turns out that nursing is not an automatic or "instinctual" behavior for human parents, nor for any of the other higher order primates. Nursing is a social behavior, and the skills needed to nurse a baby are learned skills, not unlike the skills needed to eat with a fork and knife. Babies are born with some instincts that help a new parent out (they can root for the nipple, "crawl" towards the breast, and attach themselves without any instruction or assistance), but new parents need to rely heavily on other humans to teach them how to nurse their babies. 

In cultures where exclusive breastfeeding is the norm, a new mother gives birth to her first baby already having witnessed countless other mothers nursing their babies, usually in an up-close and intimate way. In the U.S., many mothers give birth to their first baby never having even held a baby before, and without ever having seen a single full nursing session from start to finish. The breastfeeding rates in the U.S. have increased somewhat dramatically since the 1980s (when I was born), but have mostly plateaued since the turn of the century. Here is the data from 2014:

From  the CDC

From the CDC

Only 40% of babies born in the U.S. are still exclusively breastfed at 3 months of age. This means that 60% are either entirely or partially being fed with artificial baby milk (ABM), presumably via bottles. So the majority of babies that anyone living in the U.S. will see about town will likely be taking bottles (a situation that is exacerbated by low tolerance/ comfort re: nursing in public). Many, many new mothers in the U.S. aren't much better off than the gorilla in Ohio when they give birth to their first baby. They mostly have had no exposure to nursing mothers. Thank goodness human mothers have much more readily available human support than the gorilla did! Still, it's really no wonder that so many mothers struggle to make breastfeeding work in the early weeks. 

Other factors that can compound the difficulty of nursing while living outside of a breastfeeding culture are the medicalization of childbirth, and some mainstream parenting practices left over from the era wherein nearly all babies were bottle-fed. But I will save my thoughts on those factors for another day. 

"Latch"

Among all of the terms associated with human lactation and with my profession as a lactation consultant, there are none that more irritating than this particular, unfortunate term: "latch." It's a word that comes up in the bulk of the inquiries I receive from families looking for help with their new babies. 

"We're concerned about the latch."
"We'd especially like you to take a look at the latch."
"We're just not sure that the baby is latching correctly."

And, of course (at least, I hope this would be obvious!), I don't hold the use of this grating word against anyone reaching out to me for help; even when people know very little about nursing a baby, they tend to know the word "latch," and they usually have been led to believe that the baby's latch—and what it looks like—is very important. 

I even would put the young, first-time-mother version of myself into this category. Here's what I knew about nursing during my first [twin] pregnancy, when I was 22 years old: 

  1. I wanted to do it.
  2. I should feed my babies "on demand."
  3. The babies might not "latch."

Since I hadn't read any books or articles (not even one!) about nursing before my babies were born, all of my [limited] knowledge came from online message boards, where in the last week of my pregnancy, I posted a last-minute call for tips regarding nursing twins and nursing after a c-section. The other mothers of the internet didn't have much to say, but they wished me luck and shared horror stories of their babies not "latching," which was the first time I'd heard the term. Yikes, I thought. What if my babies don't "latch"?

At the hospital where my twins were born, this talk of "latch" continued. 

"How's his latch?" the nurses would ask, whenever they came into the room to check on us, and the mere mention of the word made me feel anxious and uncertain. How was I supposed to know how the latch was? I'd never "latched" a baby on before. If there's a right way and a wrong way to do it, it seemed likely that I was doing it the wrong way. 

In the weeks that followed, when I suffered with painful, cracked, bleeding nipples, I saw several lactation consultants, and always asked them to check the babies' latches. "The latch looks fine," the LCs would tell me, repeatedly. The "latches" looked fine, but nursing was still really hurting me. It didn't feel fine at all. I followed all sorts of instructional diagrams online and in the books that I'd finally thought to read, and none of the tips about how to "latch" a baby on were helping things to feel more comfortable. 

All this is to say, I hated the word "latch" even before I became a lactation consultant and had good reason to eschew it. 

For starters, as I've shared above (via Merriam-Webster), the word "latch" is not a noun, it's a verb. There is never a grammatically appropriate time to refer to a baby's "latch." The word "latch" can be used as a noun, informally, when referring to the latch on a gate. But that's not what people are talking about when they're talking about feeding babies. What we mean to say when we say "latch" in regards to a nursing baby is "attachment."

The baby is attached to the breast while feeding.
I can asses a baby's attachment at the breast.
A baby can have difficulty attaching to the breast to feed.

And this is the word—attachment—that you'll see me using here in the blog. Using the word "latch" in place of "attachment" makes it sound much more complicated that it needs to, and conjures fear and feelings of incompetence and insecurity. 

"Is she latched on right?" (New parents ask me this question all the time.)
"You tell me," I say. "How does it feel?" 

How to know that baby is attached well at the breast (hint: it doesn't really matter what it looks like from the outside): 

  1. Nursing doesn't hurt (after the initial 30-60 seconds, when there may be some residual pain if nipples are damaged).
  2. Baby is getting plenty of milk (as evidenced by weight gain and soiled diapers).


Signs that something might not be quite right with the baby's attachment:

  1. Nursing is painful.
  2. After nursing, the nipple looks misshapen (not round), and/or pale/blanched (as if blood has been drained from the tip).
  3. Baby isn't getting as much milk as she or he needs, despite frequent (~ 12 times/day) nursing (as evidenced by lack of weight gain and/or lack of soiled diapers).
     

Often, when nursing is painful, or when baby isn't able to nurse effectively, the issue isn't so much the baby's attachment as it is baby's mouth anatomy and sucking skills. An experienced IBCLC can help you to assess what might be going on inside the baby's mouth (where we can't see). The attachment can look fine and great from the outside, but if it doesn't feel good, something is amiss. And if nursing does feel good, and baby is gaining weight well, you can rest assured that your baby's attachment is just fine, even if it doesn't look anything like the way the diagrams say it "should."

 
Baby Liam in 2015

Baby Liam in 2015

 

"Milk"

Welcome to my very first blog post! I'm planning to use this space to share some of my ideas and insights about human lactation and infant care. My hope is that if I write some of my thoughts down, rather than let them tumble over each other in my brain all day, I'll free up some bandwidth for new thinking! As a bonus, perhaps you will enjoy reading along.

To start, I want to talk about the word milk

Milk is, of course, at the very center of human lactation and of raising human infants. Ideally, babies are milk-fed exclusively for their early months, and remain primarily milk-fed for the entirety of their first year of life (and sometimes beyond). In this blog, as in real life, I will use the word "milk" to refer to what Merriam Webster defines as the "fluid secreted by the mammary glands" of human mothers. I will not be using the more popular term, "breast milk" (which is actually two words). 

The reason why I don't use the term breast milk isn't just because it takes longer to say, and it isn't just because I also refrain from saying things like "bladder urine" and "mouth saliva." I believe that the term breast milk—in addition to including the word breast, which in our culture can be complicated and awkward—implies that there is something exceptional about the milk made in the human breast. Consider this common exchange:

"Are you feeding your baby?"
"Yes, I'm feeding her breast milk."

In this scenario, the parent shares that the baby is receiving breast milk, which implies that the baby is NOT being fed regular milk. There is something different and distinguished about this baby's milk, and it gets its own special name (which happens to include a woman's body part in the title). If we want people in our culture to learn to see human milk as the regular, default milk for human babies, we have to start with the very basics; we have to start with what we call it. In this case, what we call it matters. 

Moving forward, I will refer to human milk as "milk" by default and as "human milk" when it's being compared with other kinds of milks. I will refer to artificial baby milk (also known as "formula") as "ABM." I will refer to cow's milk as "cow's milk" (imagine if we called it "udder milk"?!), and to goat's milk as "goat's milk."

Welcome to the blog! Please feel free to share your own thoughts in the comments.