Keeping Baby On (Part 1): Breastfeeding Troubleshooting

Baby is a few months old now, and you’ve (finally) managed to establish a decent breast milk supply. You and baby are now more or less comfortable with each other on…and off the breast. Congrats, you’ve gotten through that first stage of breastfeeding and parenting! It may not have been easy. But perhaps, like me, you’ve also discovered that the road of breastfeeding is still quite bumpy. Some breastfeeding sessions just don’t go very well and you know it’s not a supply issue. So what could be the reason(s)?

From experience, here are 5 simple reasons why baby might pull off the breast suddenly during a breastfeeding session, and some quick solutions to help you keep baby on the breast:

Check the latch.BFingMomBabypic2shorthair
Make sure baby has a good ‘mouthful’ of breast tissue so that the nipple is far back in baby’s throat, and baby’s lips are turned out (think of fish lips). Otherwise baby may be sucking on just the areola and not getting much and so pulls off. Baby is very smart! Why work for milk when there doesn’t seem to be any there? A bad latch would also not be very comfortable for you. If you think the latch is not good, then gently detach baby from the breast (by inserting your pinky finger into baby’s mouth to break the suction) and then try putting baby on the breast again.

Baby needs a mini-break.
Let’s not forget—sucking can be tiring! Baby may simply need a little break. Stand up, turn around or go briefly to another room. Sometimes just a minute’s break or change of scenery is enough. Also a tiny break may give the breast a chance to fill up a little more in the interim. Some other ‘mini-break’ ideas: change the baby’s diaper or change the clothes, and then offer the breast again.

Change the position.

Sometimes a change in the breastfeeding position is all that’s needed to get baby to suck a few more minutes, and this may allow more milk to be pulled out of the different milk gland areas on the breast. Baby may also latch on better in a different position. Often when breastfeeding, I would use two different breastfeeding positions per side.

Another idea is to try a completely new position that you have not tried before…who knows, this could turn out to be your baby’s favorite! If you’ve tried all the conventional positions (e.g., Cross-Cradle Hold, Cradle Hold, Football Hold and Side-Lying Hold), invent one yourself or try this new position that I’ve used regularly with my own little one during the breastfeeding phase (see A New Breastfeeding Position: the “Bear Hug”).

Got gas?
Try to sit baby up and burp baby. Once a burp is out, a baby is usually happy to get back on the breast. This is especially the case for younger babies. When my little one was between 4-6 months, she would often have at least one burp when she finished one side (and multiple burps when she was younger!).

Check the temperature.
Check the temperature of the room. Is it too hot? What about baby? Know that often breastfeeding and holding baby can increase both your body temperatures (and may cause you and/or baby to sweat), so check baby’s clothes to make sure she’s not wearing too much. Baby could be feeling a bit hot and bothered!

If you’ve done this bit of troubleshooting, and these are not the reasons why baby is pulling off the breast, try not to worry too much. Baby may have really had enough breast milk to drink! As babies mature and grow, the length of time on the breast and of breastfeeding sessions in general usually decrease. Often this is because babies become much more efficient at sucking and may also need less once solids are introduced into the diet.

Moms Aware! What You Should Know About Keeping Breast Milk in the Fridge

As you may have seen by now, recommended storage times for expressed breast milk (EBM) in the freezer and in the fridge can vary quite a bit, depending on which guidelines you look at and factors like the type of freezer used.  For freshly pumped breast milk, the UK and US government guidelines are generally the same, which is that EBM can be stored in the back of the fridge for up to 5 days at a temperature of 4o C (39o F) or lower.

There is a study, cited in the American Academy of Pediatrics (AAP) 2012 position statement on Breastfeeding and the Use of Human Milk, which looked at the changes in expressed breast milk stored in a refrigerator in a hospital setting. Many factors were measured over time, including the pH, bacterial count, protein level and white blood cell counts. It found that EBM could be kept in a fridge for up to 96 hours (4 days) with minimal changes to its integrity. That’s good news. But, should expressed breast milk really be kept this long in the fridge? What about its taste?

What I have found over the months, is that the length of time the fresh breast milk sits in the fridge also impacts its taste. Very fresh breast milk tastes really good! It has a mild sweet aftertaste but is essentially quite bland. Think of 1% or non-fat cow’s milk but with a lighter, more watery and slightly sweet taste. By day 2, the expressed breast milk is already starting to taste a little ‘off’; you can taste a tiny bit of the free fatty acids from the lipases working, and a whitish layer forming on the top of the milk. By day 3, the ‘off’ soapy bitter taste is even stronger, even after mixing in the fat layer to the rest of the milk. I think at this point the baby may not be as willing to accept the milk already. If this is the case, you could try warming the milk more before offering it to baby, or use it in baby’s solids instead. By day 4, the ‘off’ taste gets even stronger. Much stronger.

The take home message? I would recommend using your expressed breast milk within 24 hours if kept in the fridge to optimize its taste and acceptability to the baby. Otherwise, definitely use it up by 4 days (96 hours). And still keep it at the back of the fridge! If you don’t think you’ll use it within 24 hours, then it may be best to freeze it, and then when you need it thaw the expressed breast milk and use it as soon as you can after it is thawed!
 

Sources:
1. Centers for Disease Control (CDC). Proper handling and storage of human milk.  http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Accessed 26 October 2013.
2. National Health Service (NHS). Expressing and storing breast milk. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/expressing-storing-breast-milk.aspx#close. Accessed 26 October 2013.
3.Section on Breastfeeding. American Academy of Pediatrics. Breastfeeding and the use of human milk. J Pediatr 2012;129: 3: e827-e841. http://pediatrics.aappublications.org/content/129/3/e827.full.pdf+html. Accessed 26 October, 2013.
4. Slutzah M, Codipilly CN, Potak D, Clark RM, Schanler RJ. Refrigerator storage of expressed human milk in the neonatal intensive care unit. J Pediatr. 2010;156(1):26–28.

Fresh Versus Frozen: The Taste of Thawed Breast Milk

Frozen thawed milk tastes different from fresh. How do I know? Because I was basically dared by my mother-in-law (MIL) to try my own breast milk (yes…). At the time, my baby was about 3 months of age and wasn’t taking breast milk well from the bottle. My MIL suggested it was the taste of the thawed breast milk, as her friend said her grandchildren had the same issue because the thawed breast milk did not taste good. I knew breast milk usually tasted slightly sweet because of the lactose content, but I didn’t really believe my MIL that there could be such a vast difference in taste between fresh and frozen to affect baby’s intake. Especially since I had learned as a dietitian that a baby doesn’t usually develop a strong taste preference until after 6 months of age. Before then it was often possible to get a baby established onto a more bitter tasting hydrolyzed formula even if the baby had been used to the sweet taste of breast milk. And after all, if the expressed breast milk had been quickly frozen, wouldn’t that slow down the lipase enzymatic action on the fats within the breast milk and so prevent the breast milk from going ‘off’ in taste? Well, my MIL then implied that if I didn’t believe her I should taste the breast milk myself. So I did. In front of her.

And okay… there IS a difference. Fresh breast milk tastes…fresh…a bit like cow’s milk but lighter, more watery and with a slightly sweet taste. The thawed breast milk tasted more bitter and metallic. I found it had to be heated more in temperature to make it more palatable tasting.

My little one still took the thawed frozen breast milk (sometimes with a bit of cajoling and distraction with a toy) from a bottle until about 4-5 months of age, then after that she seemed to get wise to the fact that it really didn’t taste very good, and so refused more adamantly to take it (even when she was really hungry). She would always drink fresh pumped breast milk though!

What I have found I needed to do was this: Give the frozen breast milk as soon as it has thawed. This means really within the first hour or two after it has been thawed out in the fridge. Doing so will keep the thawed frozen breast milk tasting as close as possible to freshly pumped milk. Any more than that, and the bitter, metallic and soapy taste starts to appear, especially the longer it sits (mainly because of the active components within the breast milk like the lipases which start to break down the fat within the milk).

Note that even if there are some taste changes in the thawed breast milk, you can still use it in the baby’s food, assuming the baby is eating at least a few tablespoons’ worth of solids in a sitting. This gets easier to do as baby gets bigger and eats more at a time. So don’t toss all your hard work of pumping away!

 

A New Breastfeeding Position: the “Bear Hug”

You’ve already heard or may have tried these common breastfeeding positions: Cross-Cradle Hold, Cradle Hold, Football Hold and Side-Lying Hold. I’ve tried all of them. But I ended up having to invent a new position basically out of necessity. I call this the “Frontal Hold” (or more affectionately known as the “Bear Hug”) position.

Why? First, I found I was getting milk lumps more easily on the right side from the traditional cradle hold, though the football hold position did help some. I also got tired of backaches from slouching and hunching over with the cross cradle and other positions. The side-lying position didn’t work as well for baby and I. Lastly, I was going to travel back to the States when baby was 4 months old, so needed a breastfeeding position that would work in the cramped quarters of an airplane seat using a breastfeeding cape.

Here’s how to do it (works best with the Brest Friend breastfeeding pillow):

  1. Sit up tall and straight, making sure you are comfortable with pillows behind you if needed.
  2. Put baby facing you between you and the breastfeeding pillow.
  3. Adjust baby’s legs so that they straddle around your waist.
  4. Use one hand to support baby’s head and neck (make sure baby’s back is straight) at a slight angle with baby’s mouth on par or level with nipple.
  5. Your other hand can be on the breast you are offering, when you bring baby’s head and mouth towards the nipple.

To help ensure a good latch, make sure the nipple goes far into the back of the baby’s mouth. Once latched on, baby should be able to suck comfortably this way. However, make sure to burp baby well in between or afterwards, as I have found that my baby often takes in a bit more air this way as a result.

If you are using the Brest Friend breastfeeding pillow, you can clip the two parts of the pillow together and pull the belt tight enough, so that the pillow holds the baby more snugly to your body. You can also angle or tilt the pillow so it supports the baby’s back better.

I started to use this new position when my baby was 3-4 months of age. This position became easier as baby started to sit up better unsupported, and as the football position got more difficult (baby’s body was longer and needed more pillows to support her body on the chair’s armrest). It came in so handy on the airplane too and prevented a lot of lower backaches! I still switch around positions during a breastfeeding session, but have used this “bear hug” position regularly for many months. I’ll have to stop using this breastfeeding position soon though, as she’s finally getting too big and sitting ‘too tall’ to latch and feed properly!

Breastfeeding Nutrition: Country Specific Recommendations

Here are a few specific nutrient recommendations for breastfeeding women in the United States (US) and United Kingdom (UK). As you’ll see, some of these differ, so choose which recommendations you want to follow!

UNITED STATES

Fish Intake & Mercury—
Fish is a good source of vitamins, minerals and essential omega 3 fatty acids. The American Academy of Pediatrics (AAP) recommends an average daily intake of 200-300mg of omega 3 long-chain polyunsaturated fatty acids (docosahexaenoic acid [DHA]). This can be met through the consumption of 1-2 portions of fish a week. The general guideline is to aim for 8-12 ounces of cooked fish a week, choosing lower mercury containing fish (examples are herring, canned light tuna, salmon, flounder, tilapia, trout, pollock, catfish) while avoiding intake of predatory fish (e.g., shark, pike, marlin, King mackerel, swordfish, tile fish) due to their likely higher mercury levels. For the same reason, choose light canned tuna instead of canned “white” tuna (albacore). If you consume canned “white” tuna (albacore), have less than 6 ounces a week. If you don’t include fish in your diet, then some non-fish sources of omega 3 fatty acids are canola oil, soybean oil, ground flaxseed and walnuts.

Calcium—
In the United States, the calcium recommendations are the same for adult breastfeeding and pregnant women (19-50 years of age) at 1000mg/day. Look for calcium rich sources like dairy products, calcium and vitamin D fortified drinks, breakfast cereals and breads fortified with calcium.

Vitamin D—
For a breastfeeding mother, 600 international units (IU) or 15 ug of vitamin D is recommended daily. It is generally easier to meet these recommended vitamin D intakes in the United States because more commercial products tend to be fortified with vitamin D. Examples are many cow’s milk, yogurts, and cheese dairy products, calcium and vitamin D fortified soy milk and juices, and breakfast cereals like General Mills Total® cereal.

Vitamin & Mineral Supplementation—
According to the AAP, there are currently no routine recommendations for maternal supplements during breastfeeding, though many doctors recommend continued use of prenatal vitamins. Poorly nourished mothers or those on selective vegan diets may need multivitamin and omega 3 supplements.

UNITED KINGDOM

Fish Intake & Mercury—
Breastfeeding women are recommended to have no more than 2 portions of an oily fish a week (examples of oily fish are fresh tuna, salmon, mackerel, sardines, herring, pilchards and trout). If predatory fish like shark, swordfish, marlin are consumed, it is recommended that no more than 1 portion of these fish are consumed a week. There is no restriction on the amount of canned tuna a breastfeeding woman can have. In the UK, however, canned tuna does not count as oily fish as they are low in the good fats and in vitamin D due to the processing methods used.

Calcium—
Calcium recommendations actually jump from 700mg a day for an adult pregnant woman to 1250mg a day for a breastfeeding mother! One cup of milk has about 300mg of calcium, so this would mean aiming for at least 3-4 servings of calcium rich products a day. Examples are dairy products like cow’s milk, yogurt, cheeses, fromage frais; calcium and vitamin D enriched oat milk, rice milk and soy milk (note that ‘organic’ versions mean these are not fortified with calcium or vitamin D); calcium fortified breads and cereals.

Vitamin D—
The UK Department of Health recommends that all pregnant and breastfeeding women have 400 international units (IU) or 10 ug of vitamin D daily. Some food sources of vitamin D include oily fish, fortified margarine and eggs. Here are also some foods on the market that are fortified with both calcium and vitamin D: certain breakfast cereals like Kellogg’s Corn Flakes®, Weetabix Crunchy Bran®, Ready Brek® porridge, and calcium and vitamin D fortified cow’s milk alternatives like soy milk, rice milk and oat milk.

Though food in the diet can contribute to vitamin D levels, it may be difficult to obtain enough vitamin D from diet alone (especially in the UK where many foods on the market like dairy products are not fortified with vitamin D). Our bodies can also manufacture vitamin D through modest exposure to direct UVB sunlight. However, factors like variable weather conditions, use of sunscreens, different skin types and cultural practices may all impact on vitamin D levels. So for those who find it hard to get enough vitamin D from the sun and their diet, a vitamin D supplement might be needed.

Breastfeeding Nutrition: Nourish Your Body!

Eating well is an important part of self-care, especially during breastfeeding. Nourishing your body can only help you in post-delivery healing, maintaining health, and in keeping up energy levels during this demanding period of life. Plus if you’re going to eat anyway, you might as well be smart about what you are having!

How much to eat?
It is estimated that a breastfeeding woman may need an extra of 450-500 calories a day, though the actual intake a woman needs also depends on other factors like body fat and physical activity levels.  How much is 450-500 calories? It’s roughly equivalent to a Starbucks’ white hot chocolate (16oz) with whipped cream, or a sandwich (made of 2 slices of bread, mayo, cheese and lunchmeat) plus a glass of milk, so not a huge amount more!

At the beginning you may not notice the need to increase your intake (this may be why breastfeeding women lose those pregnancy pounds much faster). However, as your baby’s intake at the breast increases, you may start to feel hungrier. If you’re like me, I felt like I was the cookie monster raiding the kitchen every few hours (especially after a full pumping session). I found I soon needed to add in 1-2 snacks or ‘mini-meals’ during the day to compensate and keep up my energy levels.

What to eat?
As in pregnancy, continue to aim for a varied and healthy diet, with plenty of whole grains, protein-rich foods (e.g., lean meat, chicken, turkey, fish, eggs, pulses like beans and lentils), vegetables and fruits. Continue to include at least 2-3 daily servings of good sources of calcium in your diet. These include milk, yogurt, cheese, tofu prepared with calcium sulphate, broccoli, okra, and calcium fortified drinks.

Keep meals simple so they will be easy to prepare.  If you are too tired or feel you don’t have the energy to fix yourself three proper meals in between trying to rest and breastfeed, then eat smaller ‘mini-meals’ throughout the day. Alternatively, have lots of healthful nutrient dense snacks available in the house which you can consume quickly and then rest. Examples are a quick handful of nuts, dried fruit or sunflower seeds (or combine these with cereal to make your own trail mix), bananas, granola bars, fresh fruits, tinned fruits (canned in its own juice), salads, yogurts, hummus with pitta bread or vegetable sticks, cheese and crackers, canned soup, tinned fish to make quick sandwiches, and cereal.

Hydration
Along with eating well, is drinking well too. Breastfeeding can make you feel quite thirsty so drink lots! Water is fine, but include other more nutritious options during the day as well. Examples are milk or calcium fortified alternatives (like calcium fortified soymilk, oatmilk, coconut milk, orange juice…the possibilities are endless!), frozen fruit banana yogurt smoothies, soups and broths. Sometimes it helps to have a glass ready near your breastfeeding chair so that every time your baby breastfeeds, you can have a drink too!

Breast Milk Booster — It’s Gotta Be Rest

Apart from having baby feed often at the breast, the next big breast milk booster—in my opinion–-has got to be rest. I’ve noticed that my milk supply seems to build up the fastest when I can really, properly, rest – even for a short period of time. If I can actually fall asleep for a bit (like a half hour or more), that’s even better. Actually, this all makes a lot of intuitive sense. If you are constantly up and about, running from doing one thing to the next, your body will use its energy reserves to give you the energy to keep active and moving. But if you get the chance to lie down and rest, your body will be able to direct those energy stores to breast milk production.

I think this is something we all know already, but just find challenging to do. Logistically, it can be tough especially if there are other young children in the picture. Mentally, if you’re a multi-tasker or busy bee like me, it can also be difficult to prioritize rest above all else.  Often, the temptation is, “I’ll just do this one more thing first (like check email)…” Then before you know it, the baby’s up already! But taking the time out to rest does make a difference. Try to prioritize the less important things later (like unloading the dishes from the dishwasher). Even if you think baby’s only going to take a half hour nap, force yourself to at least lie down for 15-20 min first. If baby ends up sleeping longer, then great, you’ll have time to unload those dishes. But if not, at least you’ve rested!

Rest even if you can’t sleep.  At first with a newborn, I got used to short but solid stretches of sleep between feedings. But when she turned a month old and started to get disrupted sleep from gas discomfort—so did I. She began waking up suddenly in the middle of daytime naps and often in the night, crying loudly and needing to be burped. Even though two months later these gas issues started to resolve and baby began to sleep longer stretches again, I found it still took a while for my body to adjust back to sleeping better. While baby slept soundly, I would often feel wired up and lie awake, wondering when baby would suddenly start up crying again. But during these times, I found it still helped if I tried to rest, even if I did not fall asleep.

So remember, even little snatches of rest here and there is better than none. Not to mention it’ll help you feel more recharged and refreshed to carry on when you do!