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Nancy Mohrbacher, IBCLC Answers Questions About Breastfeeding Struggles

Q&A with Nancy Mohrbacher, IBCLC 11-20-13

QUESTION 1: My milk supply for my 4-mo-old is decreasing despite taking fenugreek and pumping. Any advice? I’m not ready to give up!

NANCY MOHRBACHER, IBCLC: I’m glad you reached out. You’ll be happy to know that milk production is a hardy process. Even mothers who have never been pregnant have brought in milk for adopted babies! You just need to know how it works. First, despite popular belief, drinking water and improving your diet does not affect milk production. Your body knows how much milk to make by the number of milk removals (breastfeeds plus pumps) each day and how fully the milk is removed. (Drained breasts make milk faster and full breasts make milk slower.) If you breastfeed your baby on cue, your baby will do this for you automatically without you even having to think about it. For most women, 7 or 8 milk removals per 24 hours are enough to keep supply steady. Fewer removals usually mean decreasing milk supply. More than 8 or 9 usually stimulate a gradual milk increase. Taking fenugreek or other herbs will not help if you’re not removing the milk often or well enough. For more on how individual differences among mothers affect this and how to use this info to keep up milk production after you’re back at work, see my posts on the Magic Number concept.


QUESTION 2: I’m expecting my first baby and have gotten so much conflicting advice. Do I need to buy a nipple shield or other products to prevent or treat nipple pain?

NANCY MOHRBACHER, IBCLC: Congratulations! That conflicting advice can be a real bear! In answer to your question, treating nipple pain with products is not the best first step. Nipple pain is usually a symptom of a shallow latch, which you can adjust to eliminate the pain. A shallow latch can also reduce milk flow to your baby. Feel in your own mouth for where the roof of your mouth turns from hard to soft. It’s near that area, nicknamed the “comfort zone,” that your nipple needs to reach in your baby’s mouth to avoid or relieve pain. During the years I worked as an LC in private practice, I found that just a small tweak in how the baby latched was usually enough to go from painful to comfortable breastfeeding. Scroll down on the Multimedia page of my website to see an animated video of one strategy for getting a deeper latch. If you can’t relieve the pain on your own, rather than turning to products, see a board-certified lactation consultant, who can also check you and your baby for other treatable causes of nipple pain.


QUESTION 3: I’m a first-time mom. My baby is one month old and I go back to work in a month. When should I pump and how can I store milk for work if my baby takes a bottle every day?

NANCY MOHRBACHER, IBCLC: Great questions! The best time to pump when you’re home with baby is usually about 30 to 60 minutes after the first feeding that you’re up for the day. Most moms have more available milk in the morning. Once your baby is taking the bottle well, you don’t have to give it every day. Every other day or even every third day is usually enough to prevent her from forgetting how. Another strategy that can help is rather than giving a full feeding from the bottle, give just an ounce or so. There are two advantages to giving a “snack” rather than a “meal.” It is less likely to affect your baby’s breastfeeding pattern, which helps you build your milk supply, and it means you have more milk to store for your return to work. Keep in mind that you don’t need gobs of milk. You just need enough milk for your first day back and a small reserve to cover the unexpected. At work, you should be able to pump each day what your baby needs for the next day. For realistic pumping expectations, see my post, How Much Milk Should You Expect to Pump? Best of luck!


QUESTION 4: I’m 9 weeks pregnant and have a nursing 17-month-old. Is it safe to breastfeed through a pregnancy?

NANCY MOHRBACHER, IBCLC: Some women wean during pregnancy, but you don’t have to. There is no evidence that breastfeeding is harmful in any way to you or your unborn baby. The only caution is if you’re at risk for a premature birth. The mild uterine contractions that breastfeeding can cause may be of concern if there is a risk of going into labor early. In this case, you’ve probably been told to abstain from sex until after delivery, as orgasm has the same effect.   If your pregnancy is not high risk enough to require you to avoid sex, you should be fine to keep breastfeeding.


QUESTION 5: With my first baby, I had severe nipple pain and low supply. Now that I’m expecting baby #2, would it help to nurse AND pump after birth?

NANCY MOHRBACHER, IBCLC: I’m glad to answer. Often nipple pain and low supply go together because a shallow latch (the most common cause of nipple pain) sometimes (not always) slows milk flow to the baby. This can prevent your baby from draining your breasts well, which may have been your supply problem’s root cause. One study looked at pumping after breastfeeding in the hospital in women who had cesarean sections and found no improvement in milk supply. A better strategy is to make sure your baby gets a comfortable, deep latch from birth and nurses at least 8 to 10 times per day. (More is better!) The hospital lactation consultants may be able to help you with your latch. If not, see an LC in private practice when you get home.


QUESTION 6: My first baby will be born soon and I’m wondering if I should wake my baby to nurse at night or if I should wait until he wakes to breastfeed.

NANCY MOHRBACHER, IBCLC: The answer is “it depends.” You need to know first if your baby is feeding effectively. His weight check at 2 weeks should answer that question. If his weight gain is good (at birth weight or gaining about 1 oz. per day), you can stop paying attention to the time and wait for him to wake you at night. During the first 2 weeks, it’s fine if your newborn sleeps for one 4- to 5-hour stretch, as long as he is nursing at least 8 times during the rest of the day.  If your baby is gaining weight well, you don’t have to worry about the other details. Once he’s proven that he’s an effective feeder, you can trust your baby to let you know when he needs to feed. If a healthy baby sleeps a lot at night, he will just “cluster nurse” during the day to make up for lost time. Good luck!


QUESTION 7: Sometimes my baby gets frustrated at the breast and won’t latch on. I’ve been breaking down and giving him a bottle of formula. What else can I do?

NANCY MOHRBACHER, IBCLC: What a worry! The most important thing is not to let your breast become a battleground. If your baby is fussy, walk him, rock him, and comfort him in other ways rather that fighting at the breast or giving the bottle. What may help after he calms is to get into a semi-reclined position (try the position you use to watch TV), and lay him tummy down on your body. That triggers your baby’s inborn feeding reflexes, and he should start to bob around looking for the breast. This can even work when he’s drowsy or in a light sleep, which you can recognize by eyes moving under eyelids or other movements. These more natural breastfeeding positions often make it easier for babies to latch. Plus baby’s full frontal contact with you is calming and acts like a GPS, telling him where he is and what to do. To read more about this, see my blog post on laid-back breastfeeding.


QUESTION 8: I’m a first-time mother who has been struggling with breastfeeding for 6 months. First I thought my daughter’s constant pulling off and crying were due to low milk supply but when I took fenugreek, it got worse. I wonder if our issue might be oversupply. Is it too late to fix this problem?

NANCY MOHRBACHER, IBCLC: I’m sorry you two have had such a rough time! Your experience is proof that there really CAN be too much of a good thing. It’s definitely not too late! Many mothers end up with oversupply when they’re too diligent about pumping. How can you be sure of the cause of your problem? Your baby’s weight gain will tell you. If she is gaining twice or more the expected weight gain of 1 oz. per day during her first 4 months, it’s time to consider bringing down your milk production. If her weight gain is average, instead, consider it a milk-flow issue and adjust your nursing position so gravity gives her more control over the flow. See my blog post, The Dos and Don’ts of Block Feeding, for the specifics about these strategies.