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Home , Infant, Low milk supply

9/2/2014

Goldilocks and Her Supply: Too Much? Too Little? Or Just Right! Do we know what is normal and common? Ronda Seifert RN BSN IBCLC Strong Families AZ Coordinator Arizona Department of Services

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Baby Behavior Baby Behavior

WIC in California found that moms interpreted If you want to learn more : normal behavior as meaning that baby is not getting enough: http://strongfamiliesaz.com/ • Crying 1. Create login (quick and free) • Waking 2. Click “Professional Development” What about… 3. “Web-based Professional Development • Hunger and Satiety Cues Opportunities” 4. “Baby Behaviors”

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Newborn Stomach Getting Enough?

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1 9/2/2014

Normal Weight Gain What Is Normal? Baby’s Age Average Weight Gain • Baby behavior and feeding cues 0-4 months 4 – 7 ounces per week • Stomach size & feeding frequency 4-6 months 4 – 5 ounces per week • counts and weight gain • Cluster feeding & Growth spurts 6-12 months 2 – 4 ounces per week • Development and appearance

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Supply Issues Priorities

• Feed the baby • Protect the milk supply • Fix the problem

Mom is in the driver’s seat.

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Getting Enough? Getting Enough? Unreliable ways to tell if baby is getting enough at • How is breastfeeding going? the : • How often feeding? • Feeding frequently • How many poop/pee ? • Long nursing sessions • What color is the poop? • Sleeping through the night • Breast fullness or emptiness • Weight gain (from lowest weight)? • Amount mom can pump • How is baby behaving? • Taking bottle after feedings • Fussiness at the breast

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2 9/2/2014

Low Milk Supply: Symptoms • Baby has fewer than three stools per day in the first 3-4 weeks Perceived is • Not gaining weight well (at least 4-7 ounces Low Milk Supply per week) • Baby does not feed 8-12 times per day

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Common Causes Critical Thinking

• Scheduled feeds or skipped feeds • Is it a supply issue? • Baby has begun supplemental formula or solid • Is it a transfer issue? foods • Is there a health issue for mom or baby? • has begun • Mom and baby are separated and mom is not The possible causes are many. expressing milk while away. Some are common, some not common.

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Feed the Baby AAP’s Supplementation 1. Mother’s own milk/ • At breast when possible 2. Pasteurized donor banked milk • Mom’s colostrum/milk when possible 3. Hypoallergenic • Donated breastmilk from milk bank if possible 4. Elemental infant formula • Hypoallergenic formula – temporary 5. Bovine milk based infant formula “medicine” 6. Soy infant formula • Age-appropriate amounts 7. Water/Glucose Water

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3 9/2/2014

Supplementing Typical Feed Amount AVERAGE REPORTED INTAKES OF COLOSTRUM Baby’s Age Per Feed Intake per Day BY HEALTHY BREASTFED First Week 1-2 ounces 10-20 ounces Time Intake (mL/feed) Weeks 2 and 3 2-3 ounces 15-25 ounces 1st 24 hours 2–10 5 mL≈1 tsp 30 mL ≈ 1 oz Month 1-6 3-5 ounces 25-35 ounces 24–48 hours 5–15 (Mohrbacher & Kendall-Tackett, 2005) 48–72 hours 15–30

72–96 hours 30–60 http://www.bfmed.org/Resources/Protocols.aspx

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Protect the Supply Protect the Supply How much is enough? Guidelines for 24 hr milk production – Mom should produce 600 ml (20 oz) by day 10 Ideal >750 ml Supply and Demand: – If mom is not pumping 350 ml by day 10, then mom needs to Borderline 350-500ml use strategies to improve milk The more milk that is removed, supply. – Hand expression is best to Low <350 ml the more milk that is made. collect colostrum (spoon, syringe, etc) The less milk that is removed,

the less milk that is made.

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Low Milk Supply: Strategies Low Milk Supply: Prevention

• Put the baby to the breast often • Position/ • Increase the numbers of feedings or remove milk • Feed often – 8-12 times per day with pump. • Let baby release at end of feed • Offer baby unlimited access to the breast • Avoid long intervals between feeds • Skin-to-skin • Get help if there is an issue • Rest and relax • Breastfeed on one side and pump on the other • Express milk when separated.

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4 9/2/2014

Fix the Problem Warning Signs • Newborn who is more than 10% below • Find and fix the problem birthweight • Critical skills: • Not regained birthweight at 2 weeks old • Stools have not turned yellow by 7 days old – -specific knowledge • No urine output for 12 hours; no stool for 24 – Helping experience in lactation • Any clinical signs of dehydration – Critical thinking • 2 – 3 months old gaining < 20 g/day – Communication • Baby with lack of weight gain, significant jaundice, or unexplained weight loss at any age

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Low Milk Supply

Returning to Exclusive Breastfeeding The baby is in need of medical attention.

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Critical Thinking Priorities

• What is mom’s goal? • Feed the baby • Is baby getting enough? • Protect the milk supply • How long since mom gave birth? • Fix the problem • How much is baby being supplemented? • Is baby breastfeeding well? Mom is in the driver’s seat.

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5 9/2/2014

Feed the Baby Feed the Baby

• Get a weight check to start • Monitor poop and pee diapers and weight • Consider getting weight checks at least weekly gain to ensure adequate weight gain • By about day 5* • In baby under 3 months, anything below 20 g – Minimum of 1 poopy diaper every 8 hours, AND per day or about 5 oz per week means needs minimum of 1 pee diaper every 4 hours more supplementation • If close to time, mom can try to breastfeed and if still no poop or pee, supplemental feed

*Around 6 weeks, stooling patterns change again

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Protect the Supply Protect the Supply

• If during the first two weeks, suggest 2 – 3 • No more than one 5-hour break in a 24 hour days of marathon pumping and feeding to period for best results ramp up supply • Mother care is important, too • Offer both sides or pump from other side • Other things moms try • Cluster pumping/breastfeeding especially during day with 8-12 sessions the goal for 24 hours

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Other Tips Other Tips

• Use breast compressions during feeds • May be able to supplement less in the • Use breast massage during and hand morning when supply is generally higher expression after pumping • Consider alternate feeding methods, ie • Pump 2 min after last milk OR 20 - 30 minutes – Supplemental Nursing System, finger feeding, etc. • Hand express after or between breastfeedings – Or paced bottle feeding – Carefully consider pros/cons

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6 9/2/2014

Returning to Exclusive Other Causes of Low Supply • Cut back on supplemnentaion by a ½ ounce per feeding with a day or two between cut-backs • Health or anatomical problems with baby that • Any poop/pee decrease or lack of adequate prevent good milk transfer weight gain, bump supplement back up and • Uncontrolled maternal anemia reevaluate • Signs to consider cutting back faster – greater • interest at the breast, greater poop/pee output, • Previous breast surgery greater weight gain, baby shows signs of fullness • Hormonal problems at the breast, not wanting to finish the • Maternal medications supplement • Smoking

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Low Milk Supply Scenario

A 19-year-old client has delivered an infant who was 37 ½ weeks gestation age. Mom reports that in addition to breastfeeding, baby has been receiving formula during hospital stay and also Refer mom and/or baby to their HCP and IBCLC at home. Baby is five days old and mom reports that she has been trying to breastfeed but now her are very sore and she doesn’t know what to do.

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What Would You Do? Scenario

More info: • Baby did not spend any time in NICU • Baby has 6+ wet and 3+ poop diapers What do you suspect might be happening? • Mom estimates that baby is receiving an

additional 1-2 oz of formula about 7 times per What other information would you like to have? day • Mom reports that her have started to feel firm and a little uncomfortable

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7 9/2/2014

What Would You Do?

What do you suspect might be happening? Over abundant Milk Supply/Oversupply Is there anything else you might want to know?

What information and suggestions might you share with this mother?

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Oversupply Oversupply: Vicious Cycle

• Oversupply can have similar symptoms as a • Lipids (fats) stimulate cholecystokinin baby with colic, reflux disease, and • Cholecystokinin produces satiety (fullness) • Before considering oversupply as a possible • Mother produces large volume of milk factor, be sure baby is gaining more than the • Infant does not get to the higher fat, last milk average 2 pounds per month.

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Oversupply: Vicious Cycle Oversupply: Vicious Cycle • Cholecystekinin also slows digestion • Despite taking large volume of milk, infant continues to feel hungry and feeds frequently • Without enough fats, milk rapidly moves through GI tract • Frequent feeds stimulate larger volumes of milk • High volumes of milk = high volumes of lactose • Leads to greater volume, lower fat milk • Cycle continues and gets worse

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8 9/2/2014

Oversupply: Vicious Cycle Oversupply: Maternal Symptoms

• Infants can experience temporary lactose • Sore nipples overload (not enough lactase to break down • May leak milk between feedings the lactose) • Milk ejection may feel painful • Lactose overload may overwhelm gut, leading • Plugged ducts to green, watery stools or even mucous & in stools • • Discomfort increases, comfort breastfeeding • Low confidence in milk supply (due to baby’s increases leading to increased oversupply behavior) (Smillie, Campbell, Iwinski 2005)

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Oversupply: Infant Symptoms Oversupply: Infant Symptoms Feeding behaviors at the breast Gastrointestinal symptoms after feeding • Very fast weight gain (more than 1/2 pound/week) Hungry “all the time“ Burping, spitting up • More than the usual wet/dirty diapers Gobbles and slurps Fussy, crying • Fussiness between feedings Chokes and sputters Gassy, colicky • Continuous feeding cues even after taking Tugs or “fights” the breast Explosive or green stools* ample milk Clicking, pinching, clamping down Mucousy or blood-streaked stools** • Explosive green or watery stools “Lazy”, “loose latch” • Constantly feeding or babies may refuse to *After initial transition to yellow breastfeed **Always refer to HCP to rule out other causes

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Oversupply: Causes Oversupply: What is it?

• Switching breasts after a set amount of time • Oversupply symptoms may lead to diagnosis: • Following “rules”: “at least ___minutes on a – Milk protein side; always feed both sides; always offer the – Lactose intolerance full side” – Reflux • Pumping excessively or in addition to – Colic breastfeeding • Oversupply and one of the above may both be • Underlying issue that either causes excessive present, but oversupply may not be addressed breastfeeding or decreases mother’s let-down • Results in feeds that are lower in fat

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9 9/2/2014

Oversupply: Strategies Oversupply: Strategies Mild: • Milk production should decrease • Try limiting infant to one breast per feed (may also use breast compressions at end of feed) • Monitor infant diapers to ensure adequate intake Moderate/Severe: • Should see some improvement within a week • Allow unlimited nursing opportunities on one side for • Some may need to go longer time three hours between switching, but again, important to • Express/pump small amount of milk only to comfort on monitor baby’s diaper count the side not using • If diaper count drops, reduce time between sides • Switch sides, doing the same for next three hours, etc. • Once baby’s symptoms improve, follow baby’s • Another option is full drainage & then block feeding cues

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Oversupply: Prevention Scenario • Let baby finish the first breast first • The second breast is optional A 22-year-old client has a 3-week-old baby. • Sometimes babies will want the second breast Mom is exclusively breastfeeding, but is worried (for example, growth spurts), but many babies that her baby isn’t getting enough. She reports will be satisfied with one side that he nurses all the time but doesn’t seem • Be careful with additional pumping satisfied. He is fussy between feeds and sometimes pulls away from the breast early in the feed.

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More Info What Would You Do?

• Weight gain: 13 ounces in last week • At least 6 poops/24 hours • Poop is loud, “explosive” & sometimes has What do you suspect might be happening? mucous • Mom has forceful letdown signs What information and suggestions might you • Mom has been pumping when she feels full share with this mother? after the baby feeds

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10 9/2/2014

Breastfeeding Support Breastfeeding Support

Breastfeeding Basic Training I, II, III Registration Available on www.STRONGFAMILIESAZ.com Want to learn more about how you can support 1. Create login (quick and free) breastfeeding with your clients? 2. Click “Professional Development” 3. Click “MICHEV-sponsored Professional Development Opportunities”

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Breastfeeding Hotline Breastfeeding Support 1-800-833-4642 Arizona Department of Health Services • Free Service • Provide verbal support and information • 24 hours / 7 days a week and Breastfeeding Hotline • Multilanguage line • Certified Breastfeeding Counselors • Board Certified Lactation 1-800-833-4642 Consultant/Registered Nurse

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Questions?

• Any questions? Ronda Seifert • What did you learn Strong Families AZ that you plan to use? Breastfeeding Coordinator • Evaluations ADHS • Thank you! [email protected] www.strongfamiliesaz.com

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