August is National Breastfeeding Month.

And as much as I hate the word “journey,” allow me to tell you about my breastfeeding journey.

I figure there’s a lot of curiosity out there about a pediatrician’s breastfeeding experience. I mean I sit in my clinic rooms all day counseling about it, right? So surely it was an easy task for me? Surely I would sit in daily joyful motherhood bliss while my babe nursed happily with ease and comfort, right?

Heck. No.

In fact, I disliked a lot about breastfeeding. But I loved some of it, too.

(And guess what? GASP! This pediatrician used some formula, too! What? Did she say the F word?)

Before I gave birth to my first kid, I knew breastfeeding could be challenging for some moms. I didn’t worry or fret about it too much, though, because how hard could it be?

I mean, you just put the baby on the boob, right? I’m a pediatrician! I got this!

Ahahahahahahha.

My first kid refused to latch from day one. I worked with lactation consultants. I struggled with pain. I had his mouth anatomy evaluated (all was fine). I tried shields. I had supply issues. My kid screamed. Every. Nursing. Session. And I cried every nursing session. His reflux was constant and affected positioning, length of feeds, and general happiness.

My postpartum anxiety was vicious. And made everything probably 10 times worse than it already was.

So, I decided to pump. Exclusively.

And it was the hardest damned thing I’ve probably ever done.

It satiated my need for control in a situation where I felt I had no control. But it was hard. And mentally and physically exhausting.

I’d pump in my office many times a day, running late for patients and adding stress to an already stressful day. And while my also-pumping work partner would pull out 10 ounces at a time when she pumped during lunch with me, I’d get a measly 3 or 4.

And every day, I went into the bathroom and cried. What was wrong with me? Why was motherhood feeling so robotic and protocoled and cold? Why did I cry for 45 minutes if I spilled a bottle?

But I knew pumped milk was so beneficial to my baby. So I kept on going. For 6 months. Until my supply tanked because I couldn’t pump enough at work. So we used formula. And guess what? My baby survived. And I survived.

It took such a mental toll on me to not be able to breastfeed my child that when I was pregnant with my second, my husband and my mom both nervously asked me…”you have some cans of formula just in case…right?”

They asked me this out of the kindness of their hearts, and I responded with, “yep! In the closet!” because I too remembered the dark days. And I wanted the experience with my next baby to be different.

And it was different.

Guess who breastfed like a champ? My next kid.

And the breastfeeding experience was great. And flawless. And so easy. And tear-free.

I loved bonding with my child in this special way. I loved feeling like nutrition and protection were transferred to her from my body. I even loved the exhausting 3 am feeds.

So why tell you all this?

To let you know that every mother is different, just as every child is different.
To let you know you aren’t alone if you felt breastfeeding was a struggle you totally weren’t prepared for.
To let you know even the professionals are human, and struggle just as much as you do.
To let you know it is okay to both love and hate breastfeeding.
To let you know I (and any pediatrician) will never judge you for the choices you make in how you feed your child.

How long should I breastfeed?

It seems like a simple question, but not one I feel I can answer with an exact time frame.

The World Health Organization and UNICEF recommend breastfeeding for two years, while the American Academy of Pediatrics (AAP) suggest “one year or longer.” Though these seem slightly varied, all agree that exclusive breastfeeding is best practiced until 6 months when solids are added. None offer an upper limit to the duration stated.

A recent study in Pediatrics states, “increased duration of breastfeeding… protects against infections requiring hospitalization in the first year of life but not hospitalizations or symptoms of infection at home beyond the first year.”

But this duration of breastfeeding may not be possible or sustainable for some families.

So how long do I recommend?

Short answer: For as long as you can... until you no longer feel served, available, able, or mutually fulfilled. Until you’re done.

Breastfeeding is certainly a labor. It doesn’t come easy to everyone. Some actually hate it and look forward to the day they can close the chapter and move on.

For those moms, the time may be now, because in the U.S., we do have alternative-milk options that do a great job in growing our kids.

But it is important to understand that breastfeeding doesn’t have to be all or nothing. Any is better than none. A week is better than a day. And there are benefits to two years that will exceed the benefits of a year.

So on the other end, when should we call it quits?

The answer for me is the same: For as long as you can... until you no longer feel served, available, able, or mutually fulfilled. Until you’re done.

And if it feels like you have to stand up for your feeding journey, because you buck the cultural norm here in America, the AAP has your back:

“Data on the scientific foundation for an age above which is appropriate or harmful to the child to continue breastfeeding do not exist. Nor are there reported risks to this method of social/nutritional interactions.”

Breastfeeding a toddler isn’t weird.

As always, I stand firm in my word.

If the baby is growing, if the momma is happy, and if the baby is happy then we are doing things right-breastfeeding, formula feeding, some of both.

Please reach out to me for coaching, encouragement, and ongoing support, so I can help you to meet whatever goal you have made to feed your child.

Is breastfeeding worth the possible exposure to Covid-19?

Short answer: yes.

Unfortunately, the risk of COVID-19 is everywhere in our lives right now, but the reality is your baby needs another human to survive. So regardless of the way your baby gets their nutrition, having them completely secluded from the world, or attempting to limit their exposure to you, is not only impossible; it's also not a good option for optimal health and growth as well as bonding for your baby.

As always, the way you feed your baby is a personal decision, but it doesn’t change the fact that breastmilk provides protection against many illnesses and is the best source of nutrition for most infants, even and especially during this world health emergency.

What precautions should a well mother take?

• Practice skin to skin, especially immediately after birth during the establishment of breastfeeding.
• Maintain social distancing. In the UK, this time of lockdown and isolation has shown that without the constant stream of visitors, mothers and babies have had better opportunities for uninterrupted bonding, therefor mothers have a better supply, and babies have quicker weight gain.
• Wash your hands before feeding and frequently throughout the day.
• If pumping, limit the people who feed your baby bottles.
• Routinely clean and disinfect surfaces.

But what if you are diagnosed with Covid-19?

In limited studies on breastfeeding women with COVID-19 and other corona virus infections, the virus has not been detected in breast milk; however the bigger risk is likely transmission through respiratory droplets.

With precautions in place, WHO and the CDC both agree that the benefits of breastfeeding are outweighed by the risk.

If you are sick and choose to direct breastfeed:

• Wear a facemask and wash your hands before each feeding.
• Avoid touching your or the baby’s eyes, nose and mouth.
• Continue skin to skin.

If you are sick and choose to express breast milk:

• Express breast milk to establish and maintain milk supply.
• Use a dedicated breast pump.
• Wash hands before touching any pump or bottle parts and before expressing breast milk.
• Follow CDC guidelines for proper cleaning and disinfecting recommendations of pump parts.
• Consider having someone who is well feed the expressed breast milk to the infant, if possible.

Breastfeeding is a key preventative health step, especially during a pandemic.

Talk with your pediatrician about recourses that are available for help during this time. Cook Children’s Virtual Lactation services are available: Virtual Lactation Consultation.

My first question would be, “how do you define ‘all the time’?”

Some people have unrealistic expectations for a breastfeeding baby. By rule, we know that they need to eat 8-12 times per 24 hours to sustain milk supply and growth. These feeds are rarely consistent by the clock’s standards, so throw the “two to three hour” rule out the window.

During those first couple of months, it tends to take 45 minutes to an hour per feed by the time you are able to get the baby stimulated enough to stay awake, fed on side one, burped, fed from the other side, and back down. The bigger the baby gets, the better they are at removing milk and the duration of the feeds will shorten.

Simple math tells us that if a baby is eating every 2 hours for an hour at a time, that is half of your day—and yes, “all the time!” But it's also completely normal.

Cluster feedings, do occur, from time to time as well, as a way for your baby to adjust your milk supply to fit their growing needs. The baby may cluster the night before your milk comes in, and again between one and two weeks when they reach their birth weight and attempt to double your milk supply from the one ounce they were getting to two, per feed.

Expect more clustering during growth spurts, as the baby continues to adjust the supply/ demand, although the older the baby gets, these are often less noticeable.

Try and not let the demands of the baby during these times get you down. It is not an indication that you do not have enough milk, nor does it last very long.

• No sensation of a let down
• No longer leaking milk
• Mom’s breast do not feel full (or engorged) anymore
• Unable to produce milk with a pump
• Baby does not stay at the breast as long as mom would like

Though some of these things may cause reason to look further, none are indicative of a poor milk supply.

The best way to gauge adequate supply is growth.

In the first few months of life, we expect babies to gain close to an ounce per day, and double their birth weight by 5 months.

Since you may not always have a scale handy, ask yourself questions like:

• Do you hear swallows during the feed?
• Does your baby seem content after the feed?
• Is your baby pooping 4 or more times per day? (this number falls around 3 months)
• Is your baby having 6 or more pale wet diapers per day?

If you answered these questions “yes”, then it is likely the baby’s weight is climbing as well. If some or many of the answers were “no”, then you should follow up with your child’s pediatrician for a weight check and/or evaluation.

Though most people think that a crying baby is ready to eat, crying is actually the last cue and a crying baby is more difficult to latch.

Earlier indicators may include:

• Wiggling around
• Smacking or licking their lips
• Bringing their hands towards their mouth
• Rapid eye movement
• “Rooting”

Before your baby can speak words, this is the first way our children communicate that they are hungry.

If your baby becomes completely overwhelmed, upset, and inconsolable before the subtle cues listed above, it is best to take a moment and calm your little one before beginning to feed.

Recognizing and responding to the early hunger cues jumpstarts good communication between you and your child as well as decreases the anxiety that can be caused between you both when emotions are at high.

Cradle and cross-cradle, football, side-lying, and laid-back nursing tend to be the favorites—while an older baby, especially those who nurse into toddlerhood, tend to take an unorthodox approach that looks more like gymnastics rather than feeding.

No matter the position, the goal is to get a deep latch for effective emptying of your breasts. Make sure to align the baby so that they’re entire body is rolled into yours, belly to belly, and not twisted. A good trick is to check that the baby’s ear, shoulder and hip are all in line.

It is best to work through different positions until you find something that is comfortable to you. Different babies, moms, stages, and even some diagnoses may indicate a different position, so don’t hesitate to try something new!

For moms who plan to continue nursing and pumping to provide their baby breastmilk, it becomes even harder.

It becomes so hard, in fact, that some moms decide they can't continue to breastfeed and stop altogether. For some moms, their insecurity in breastfeeding is the last straw that convinces them that going back to work will be too hard.

This is why providing lactation support to nursing moms throughout their journey is so important. It does not matter if they plan to return to work in weeks, months or even longer, support can help ease the transition back into the workplace.

Holly Erwin, Cook Children's Virtual Lactation Consultant says, "I believe there are three critical times that working moms need support in their lactation journey. First is education and support before their baby's birth. The second critical period comes in that first week after birth to help establish a solid, foundational milk supply. Finally, moms often have extensive questions about how to keep their supply and feeding up when they return to work."

In addition to benefits in mom's peace of mind, providing support for breastfeeding has shown to benefit the employer in several ways, including:

1. By decreasing overall healthcare expenditure due to the health benefits of breastfeeding (estimated approximately $2000 per employee)

2, By decreasing lost work time due to childhood illness who are breastfeeding

3. By decreasing turnover in employees after maternity leave (the national average is 59 percent but some lactation support programs report retention rates as high as 94 percent).

Cook Children's Virtual Lactation program has a simple, low-cost solution to providing the support that working, breastfeeding moms need. They partner with employers to find a customized solution that meets the needs of their employees at each of these critical stages.

Packages can include classes prior to birth and when approaching time to go back to work, personal consultations with an international board certified lactation consultant (IBCLC) and assessments of pumping spaces and other accommodations necessary to maximize a working mom's lactation success. Because of the virtual nature of the program, employers can know that their employees are receiving great care without the high cost of in-person lactation consultation.

If you wish to contact us with questions, or need help accessing our virtual lactation consultation services, please contact Holly Erwin at lactationconsultation@cookchildrens.org.

Schedule an appointment with our virtual lactation consultant.

Sometimes I’m asked, “Why is breastfeeding so important to you?”

Honestly, 10 years ago, I was so close to not knowing the answer. I was struggling and ready to quit, before I finally reached out for help.

Eventually I fell in love with breastfeeding and made it my passion to help any mom who asked for help, find her love for it as well.

When I consult with a new mom, I usually start by talking about the milk itself.

Human milk is made specifically for humans. I wouldn’t give a rabbit baby milk from a horse, if I had plentiful rabbit milk.

Though, there are some women who don’t make milk (or enough to suffice), that is not the case for the vast majority.

The carbohydrates, fats and proteins are exactly what our human babies need to thrive. It’s pure, organic, and no risk involved with additives or preservatives or contaminated water.

Breast milk is full of antibodies, and hormones, and probiotics that are invaluable to our children's health.

Our supply is ever-changing and tailored to our children’s needs, through growth or illness, our milk actually reacts before we do as the saliva exchanges between baby and breast.

Here are just a few of the benefits of breastfeeding:

• Breast milk is free.

• It doesn’t know social status or the thickness of your wallet.

• There’s no mixing, measuring, washing or preparing.

• At midnight and 3 a.m., it is warm and ready to serve.

Then there are the facts:

• Our breastfed children are at a lower risk for obesity, diabetes, asthma, diarrhea, ear infections and some childhood cancers.

• The risk of SIDs is also lower in breastfed children.

• For us as the mother, breastfeeding also lowers our chances of osteoporosis, breast and ovarian cancer as well as helps with postpartum depression.

Finally, the physical and emotional connection between you and your baby is powerful.

Eight to 12 times a day, you have the pleasure (although to be honest I know sometimes it feels like you are forced) to sit and bond with your baby for 45 minutes or more at a time in the early days. Talking, singing and eye contact are a positive byproduct of the inability of anyone else being able to help you feed your child.

Skin to skin is the best way to regulate core temperatures, heart rate and blood sugars; and breastfeeding creates a natural and unforced space to do so.

Breastfeeding is natural. I learned that lesson a decade ago and continue to see its benefits with the thousands of moms I’ve helped over the years as a lactation consultant.

Schedule an appointment with our virtual lactation consultant.

For More Information On This Topic

• Virtual Lactation Program at Cook Children's
• 'Am I Making Enough Breast Milk?'
• New Study Shows Breastfeeding Decreases Risks Of SIDS
• What you need to know about breastfeeding and your baby

Most pediatricians recommend breastfeeding as the primary source of fluid intake for up to one year of age (even longer is fine).

For those who choose not to or could not breastfeed, I recommend an iron-fortified formula until one year.

After one year, a healthy, normal developing children should be transitioned to a well-balanced diet.

Cow’s milk can be used as an easy source of calories, protein and calcium but there’s nothing magical about it. If your child doesn’t like it, or you choose not to, just make sure that they are getting a nice rounded diet.

So, what about toddler formulas and toddler drinks?

The formula companies would like you to believe that they are an essential part of a toddler’s diet. They have added components to make them more attractive including probiotics and DHA. They make the cans look similar to your infant formula, to make it feel like the transition is expected and necessary.

But, I think you can and should skip them, unless instructed by or prescribed by your pediatrician. Here are 3 reasons why:

Many of them have ingredients that I wouldn’t recommend for toddlers anyway: corn syrup and other caloric sweeteners for example.

We really don’t know much about what giving DHA to a toddler adds to his or development or intelligence. If you are worried about it, add some fish to your toddler’s diet.

Most kids get plenty of calories and nutrients from other food sources. They don’t need the added calories and the extra nutrients are unnecessary except for the pickiest, most restrictive eaters.

So, what is toddler formula?

Mostly hype and marketing.

What should you do about it?

Unless instructed by your pediatrician, save your money for college…and I mean it.

Here’s the calculation:

Assuming three 8 ounces cups of toddler formula per day, you will need about 70 cans of toddler formula from 12 to 24 months. Each can costs about $20. That’s a total of $1400 during that year. If you invested that $1400 over the next 16 years (until they reach college age) and averaged 10 percent growth, you’d have about $6,500 by the time they reach college age.

As a lactation consultant, I often hear regret from moms when they state that they “only nursed for ...” (insert perceived short time here.)

That always bothers me, because any distance that a mom makes in her breastfeeding journey, is a win to me.

New research also agrees, showing that moms who breastfed for just a couple of months, may have a significant reduction in the risk of SIDS.

In the United States, more than 80 percent of mother’s begin breastfeeding in some capacity at birth, but the number drops to about 22 percent for exclusive breastfeeding at 6 months.

Statistics like this may beg the question to some moms, is it worth doing at all, if you don’t plan to go the distance? And new research says, yes! Absolutely!

It does not have to be an all or nothing type of decision.

Realistically, I know that some mothers have no interest in breastfeeding from the start, while others find themselves at barriers that seem impossible to overcome, and decide that formula is a better option.

The truth still remains, the longer you breastfeed, the greater the benefits will be to you and your baby, but this new study shows that breastfeeding for at least two months cuts a baby's risk of Sudden Infant Death Syndrome almost in half!

SIDS is the leading cause of death in babies between 1 and 12 months, so this is not information to take lightly.

Interestingly, this study also showed that partial or combination feeding (breastfeeding and formula feeding) was also beneficial in lowering the risks, which was great news for the mommas that were not able to sustain their infant 100 percent from their breastmilk. However, exclusive breastfeeding, and longer durations did in fact decrease the risk of SIDS even lower.

At the end of the day, babies need to eat — and ultimately that’s our entire goal. Regardless if they are fed from the breast or the bottle, we believe we will get to the same outcome; beautiful, smart, thriving kiddos.

That said, breastmilk has many exciting benefits to mom and baby both. And if it is part of your plan, I am here to help you and baby reach whatever goals that you have set for yourself!

About the Author

Holly Erwin, LVN, IBCLC, is the virtual lactation consultation at Cook Children's. As a mom of three boys and has worked as a pediatric nurse for over 11 years within the Cook Children's Health Care System. When not working, she spends her time running to and from sports for her boys, being outside with her family and dreaming of traveling with her husband of 10 years. For now, she settles for their bi-annual date-night! Click here to learn more about the Virtual Lactation Consultant Program.

Through her own children and the thousands of moms that she has helped over the years, Holly found a special interest in infants and breastfeeding. In 2015, she became internationally board certified as a lactation consultant and now works as an IBCLC virtually through the Cook Children's telemedicine department.

Often, moms perceive that they do not make enough milk because they do not make “extra” milk.

Other times they think the baby is eating too often, or the breasts feel too soft, or the baby is fussy at certain times of the day, or they are unable to pump much milk.

Many complain they do not leak, that their baby nurses quicker than he or she once did, or that they are unable to feel a letdown.

Reality is, that none of these things mean that a mom has inadequate supply.

As the virtual lacation consult at Cook Children's, I ask questions like:

• Is the baby is growing?
• Are they having plentiful output (poops and urine diapers) each day?
• Are they waking often to feed and seeming satisfied after?

Since breastmilk is easily digested, breastfed babies may eat more often than bottlefed babies at somewhere between 8-12 times in a 24 hour period. The baby will be described as alert and active, and seems satisfied after feedings; often times with relaxed hands. Mom will also report hearing swallows during the feed.

The greatest indicator of sufficient milk intake is weight gain, though an initial loss is normal and expected as they shed the extra fluid in their tissues. Once the milk supply is in, we expect most babies to gain close to an ounce per day. After 3-4 months, the number will gradually slow down.

Another reliable indicator is output. By day 6 we expect to have 6 pale and mild smelling wet diapers and >4 bowel movements that have transitioned to the yellow, mustard, seedy stools. Over time, the number of stools will fluctuate and breastfed babies may go many days without a BM as their body is absorbing all of the nutrients. Even then, we expect soft and profuse stools.

The older the baby gets, the more adequate they feed, therefor spend less time at the breast and since many mothers do not feel their letdowns, that nor the firmness of the breast tell us how well the infant is being fed.

Virtual Lacation Consultation Program

Connect to an International Board Certified Lactation Consultant (IBLC) from the comfort of your own home. When caring for a newborn, it is important to have support for successful breastfeeding and nutrition. Cook Children's now offers that to you and your baby when and where you need it: in the comfort of your home. Click here to learn more about the program.

Schedule an appointment now

Consultation topics include:

• Correct latching
• Milk supply
• Feeding schedules
• Pump options and supplies
• Pumping routines/schedules
• Return to work planning
• Nutrition and skin care
• Newborn positioning
• Milk storage
• Pain or possible infection

Meet our Lacation Consultant

 

Holly Erwin, LVN, IBCLC, is a mom of three boys and has worked as a pediatric nurse for over 11 years within the Cook Children's Health Care System. When not working, she spends her time running to and from sports for her boys, being outside with her family and dreaming of traveling with her husband of 10 years. For now, she settles for their bi-annual date-night!

Through her own children and the thousands of moms that she has helped over the years, Holly found a special interest in infants and breastfeeding. In 2015, she became internationally board certified as a lactation consultant and now works as an IBCLC virtually through the Cook Children's telemedicine department.

1. I’d be Terrified the Day my First Child was Born. Guess what? Reading tons of books about the health of children makes you no less prone to the paralyzing fear that arrives when that new cute little elephant-in-the-room appears. I wish they came with an instruction manual instead of a placenta.
2. Breastfeeding Ain't Easy. I had a lot of difficulties breastfeeding one of my children. He had horrible reflux, a poor latch, and a stubborn disposition. I thought, "hey – breastfeeding shouldn’t be that bad, right? You just put the baby on the boob and they figure out the rest!" Nope. It’s no wonder there are some wonderful people out there who dedicate their whole career to helping women breastfeed. And guess what? I had to use some formula to get my kid through his first year. And that’s OK.
3. Children Sometimes (All the time) Don’t Go By the Book. First teeth don’t always appear when the books say they do. Weird rashes never look like the pictures online. My daughter had lots of motor delays, way past when the books said she should….and she’s fine now. It takes the experience of a good pediatrician to let you know when to worry, since all kids are so different. We gain experience via treating thousands of patients with time. I had to take off my pediatrician hat and only wear my mama hat when it came to my kids. And had a great pediatrician reassure me that everything would be OK.
4. Fevers Make Me Worry, Too. My son once woke up with a 105.6F temperature when he was a toddler. Of course I was supposed to be seeing patients in the office 20 minutes later. That was one of the most difficult mornings of my life. I had to choose who to care for – my son, or my patients? I took some deep breaths and tried to talk myself through what I tell my patient’s parents. Warm bath, dose of ibuprofen, lots of snuggles (with Daddy). He was fine. But it reinforced why I’ll never judge a parent who is worried even about the tiniest of temperature elevations. 
5. Living with a Toddler is Like Living with an Irrational, Angry Drunk Person. I’d read all the books about effective behavior management. Learned techniques for distraction, offering choices, creating reward charts. But when your three year old is flailing on the floor, mopping the tile with his Oscar-worthy tearfest all because I offered the blue plate instead of the red one…one questions how many bottles of wine to buy for the week.
6. Explaining Simple Things Can Become Very Difficult. “Why is that man in a wheely-chair, Mommy?” “Why did Harper’s dog die? Where did he go?” “How do planes work?” “How come kids go to different churches?” Being a board-certified pediatrician doesn’t mean that I don’t struggle with how to explain things to my kids. I want to be fair and accurate and informative…and somehow word it in a way that my little people understand it. It’s hard, I know. And I can’t promise I do it any better than you. But like you, I’m trying my best!
7. The Online Mothering Community Can Be Both Supportive and Judgmental. It really does take a village to raise a child. And I really hadn’t dabbled in the online world of mothering until I became one. What are the best breast pumps available? Where are the best parks in town? Which restaurants are most kid-friendly? I loved all the readily available advice I found online, but with that help also came the judgmental comments, the guilt, and the unintentional comparing of myself to others. I quickly put a stop to the latter in my mind – and now understand how to better reach my patient moms, who struggle with this dichotomy of feelings social media can conjure.
8. Becoming a Mom Doesn’t Mean I Have to Change Who I Am and What I Love. I was fiercely independent and very driven before I had kids. This hasn’t changed since my two little turkeys came into the world. It did however change how much time I’d have to practice my hobbies and be the best doctor I could possibly be. My lifestyle had to change a bit, but I’ve found that staying true to what you need to be happy – whether it's picking up a camera, a book, getting some time at the gym – makes you a better mom. Do it, and don’t feel guilty about some time to yourself.

I share these pieces of vulnerability and advice with you so that you know you’re not alone. Being a great mom means many things, and know that even childhood experts have their daily struggles. I’m still learning every day. And I always tell my patient’s moms: my two best teachers are my kids. At the end of the day, no matter how many arguments and challenges have ensued, if your kids know they’re loved, you’ve reached beautiful success.

Whether it’s bottle feeding or breastfeeding, you may have some questions or concerns – things that many other parents have also questioned! If not, or maybe you’re just not sure, speak to your pediatrician about a possible feeding evaluation by a speech-language pathologist (SLP). Build or re-build that bond. There’s lots that can be done to help and it will have lasting effects! Let’s take a look at three of the most common problems moms have and suggestions on what can be done about them.

1. Problem: Baby won’t stay latched during breastfeeding or falls asleep.

The best intervention for saving breastfeeding is the earliest intervention. Getting help from a lactation counselor or consultant before you feel like throwing in the towel will help to alleviate some of the frustration you and baby may be experiencing. Don’t wait - below are some resources you can contact. The WHO’s (World Health Organization) stance is breastfeeding serves a nutritional purpose for children until they’re at least 2 years of age! So keep it up, Mama!

2. Problem: My baby coughs, chokes, and is simply a messy eater.

If a baby is coughing, choking or losing milk from around the bottle when feeding, stop what you’re doing and find a nipple that may flow a little slower. Despite their very new presence in the world, babies are usually very good communicators if we’re really “listening”! They may be telling you that the milk is coming faster than they can swallow it. This might be a really easy fix. However, make sure your feedings are not taking too long and baby is getting enough. If you’re unsure, ask for help.

3. Problem: My baby spits up more than what I feel is normal.

Dr. Smith just wrote a very informative and thorough blog about gastroesophageal reflux and how it impacts feeding. Take a look at what he has to say about it and compare it to what you are seeing in your child. While the majority of cases of reflux resolve on their own around 6 months, as SLPs, we do see infants and children whose eating habits have been severely affected by it. Make sure to make notes about your baby’s behavior and discuss them with your pediatrician!

Learn more from the Tarrant County Breastfeeding Coalition

Those probably won’t be the words that are said, but it might be the message that you hear.

Breastfeeding can be a tricky thing and many different problems can lead to a poor latch or such. One of the most blamed is tongue-ties. We should be careful not to attribute every nursing problem as a tongue tie because it can lead to unnecessary procedures, stress and a lot of time wasted on the wrong things instead of finding the real reason.

A tongue-tie is an attachment of skin and/or muscle below the tongue that restricts the movement of the tongue. Defining what is too tight is often very tricky and often two providers will disagree as to whether a tongue-tie is present.

Tongue-ties can lead to three problems:

1. Difficulty with breastfeeding - Tongue-ties can lead to poor or painful latching.

2. Difficulty with speech - Certain sounds require free movement of the tongue but children often accommodate and are able to speak clearly despite having a tongue-tie.

3. Difficulty with kissing - Another activity that requires free movement of the tongue. Although you might find them being a terrible kisser a benefit as a teen-parent, they might disagree.

When you or your doctors are checking your baby, there are a few signs that might points toward a tongue-tie:

• Obviously short attachment that inserts near the tip of the tongue
• Tongue never passes out past the lower teeth or lips
• Notched appearance of the tongue due to the attachment (like a heart)

If your baby is having breastfeeding problems and there is agreement that it is because of a tongue tie, treatment involves a simple procedure to either clip or laser the attachment. Most ENTs and dentists perform this procedure in the office and the baby goes right back to nursing immediately (often moms report feeling a difference right away).

Making the decision to treat an older child with tongue-tie is usually more difficult. The symptoms and benefit of treatment are not as clear and there are often other means of treatment, such as speech therapy, that can be tried first.

About The Author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in 2017.

ENOUGH MILK ON DAY ONE?

Many parents worry their baby is not getting enough milk. Did you know a baby’s stomach is the size of a cherry when first born? And the drops of milk you are making the first day or two are normal! The milk you make these first days is called “colostrum” and is highly concentrated, yellow, and sticky, full of easy to digest carbohydrates and proteins that help your baby fight off infections.

SUPPLY AND DEMAND:

The more you breastfeed, the more your brain will make hormones that increase your milk supply and switch it over from drops of colostrum to larger volumes of mature milk. The larger the “demand” for milk, the larger the supply you will make. That is why frequent breastfeeding in those first days after birth are crucial! A general goal is 8-12 feeds during a 24 hour period. Watch the baby for hunger cues like opening their mouth, putting their hands to their face, sucking on their hands, or moving their head around as if they are searching for something. Your baby might even begin to cluster feed, where the baby will want to feed seemingly right after you just fed them! This is their way of getting your milk supply to come in. They cannot overfeed at this stage. Sometimes pumping during this stage can be beneficial to the supply/demand effect. The more you stimulate the breasts, by direct breastfeeding with the baby, and by using a pump, the more milk you will produce. To get an idea of what amount is typical, see the chart below for average volumes of milk intake.

MILK COMING IN

Mature milk usually will come in around day 3-4 of life and will be creamy, fatty, and white. Your breasts will likely feel firm, warm, tender, and full. But remember it can take up to four days for this to happen. If your milk has not come in by day 4, see your pediatrician and your OBGYN in addition to optimizing breastfeeding techniques with a lactation consultant.

LOSING WEIGHT (For baby, not mom!)

Some weight loss in the first days of life is normal. Your pediatrician will check the baby every day in the hospital and again a few days after leaving the hospital to make sure the baby’s weight loss is in a safe range. It is normal to lose up to 10 percent of birthweight in the first week, so for a 7 pound baby that means losing up to 11 ounces. Once the milk is in, the weight should start going up, and babies are expected to be back up to original birthweight when they are 2 weeks old. In addition to weighing, a good way to gauge if the baby is hydrated and getting enough from feeds is to check the number of wet diapers. Lots of full wet diapers means your baby is staying hydrated from feeds. If weight loss is beyond the normal range, your pediatrician will guide you through ways to help, which can include supplementing and/or pumping.

IT HURTS!

The most common cause of discomfort with breastfeeding is not having the right latch onto the breast. Try to make sure that the baby is opening up wide to get the entire areola and not just the nipple. You may need to take the baby off the breast and try again if the latch is not right. Both lips should be open wide and curled outwards if the latch is ideal. Lactation consultants in the hospital can help you each day to make sure you and your baby have a good latch. You can also try to use Lanolin creams to help soothe your nipples after feedings. With the proper latch onto the breast, your discomfort should be a temporary issue that gets better with time.

PACIFIER USE

Sleep deprivation combined with a crying infant can make pacifiers a tempting choice in the first days of life. However, studies show that pacifiers are best introduced AFTER breastfeeding is “established” meaning it is going very well, typically at 3 weeks of life, to prevent the baby from being confused between the pacifier and the nipple. Many parents don’t know this, but pacifiers are actually recommended because in the long run they reduce the risk of sudden infant death syndrome. So DO use a pacifier, but try to wait until feedings are going well first.

PRACTICE MAKES PERFECT

I always grew up hearing my dad say “practice makes perfect!” I wonder if that’s why I ended up becoming a doctor. I got used to practicing new things over and over again until it felt like second nature. The same can be said about breastfeeding. It is a skill, and it takes practice and most importantly, patience, but sleep deprivation added into the mix can make this easier said than done! If you are looking for further breastfeeding support from other parents, more resources, lactation consultant recommendations, or free breastfeeding classes, check out the following resources:

• Breastfeeding Tarrant County Coalition website
• Mobile app LatchMe
• Mobile app LactMed - information about safety of medications and their effect on babies through breastmilk

Happy feeding!

Dr. Rachel Hamilton

About the author

Rachel Hamilton, M.D., is a pediatrician at the Henderson Clinic. To make an appointment, call 817-783-4109. Dr. Henderson grew up in the Dallas/Fort Worth area. She obtained her bachelor’s degrees in chemistry and biology and graduated as a president scholar from Southern Methodist University. She completed medical school at the University of Texas – Southwestern Medical Center in Dallas and pediatric residency at the University of Texas at Austin – Dell Medical School. She is a member of the medical honor society Alpha Omega Alpha, and has been recognized for humanism in medicine. She is married to David Hamilton and enjoys traveling, SCUBA diving, bass fishing and other outdoor activities. Her favorite aspects of being a doctor include life-long learning and the joy of helping children live fulfilled, healthy and happy lives.

Here are four reasons I don't recommend putting a breastfed newborn on a feeding schedule:

1. They need comfort and bonding. Imagine being thrown into a brand new, anxiety-provoking environment with no skills for calming yourself and no way of escape. Plus, the person who can give you comfort is right there. Sure, you can cuddle them to help, but sometimes they just need to nurse.
2. They are hungry. I can't wait three hours to eat. I'm pretty sure if I could only eat 1-2 ounces of a liquid meal, I'd be starving before three hours came up again as well.
3. Scheduling can hurt your milk supply. Frequent feeds help your milk come in. I've seen too many babies who've been on a rigid schedule come in at 1 week with lower weight gain. Then we are scrambling to get mom's milk supply up so that they can maintain breastfeeding.
4. They will find their own schedule. Implementing a rigid schedule out of the nursery is not necessary. By paying attention, you can discover an ideal schedule for you and your child and help them keep to that without having a rigid schedule.

Then, I was blessed to have a beautiful son...

….who decided that I needed to be re-taught a few things about children.

And by a few things, I mean everything.

Don’t get me wrong – you don’t have to be a parent to be an excellent doctor. I still dish out the same advice. The books and studies are spot-on and I’m going to give it to you straight. Breastfeeding does provide the best nutrition for babies. But I understand the pain you’re going through to meet that goal. And I understand the frustration of having a child who just won’t latch on. And I understand now why you look at me, with a crazy twitch in your eye, when I tell you to try an extra pumping session a day to build up your supply, mama. I hated that thing, too. Can anyone say “dairy cow”? And guess what – formula isn’t poisonous. I wasn’t physically able to meet my full breastfeeding goals with my kid – there’s no judgement here if you grab that can. And it’s okay if it makes your relationship with your child happier, healthier and more fulfilling.

Our car seat remains rear-facing at 18 months. It’s been proven to be five times safer than forward-facing. I’m sorry for my lecture during your little one’s checkup. And oh yes, I too want to rip my hair out when I can’t reach over far enough to give my kid that 400^th toy to keep them quiet on the trip to grandma’s.

“Crying it out” was a tough one for me. Pre-child, it was so easy to coach parents - encourage them to drop the constant rocking, the running into the nursery at all hours of the night, the fear of allowing their child to cry in order to learn put themselves to sleep. Then I went through it with my son. Let’s just say I give the same advice now (it really does work) …and recommend a glass of wine for every 15 minutes of crying. I probably cried more than my kid did. Motherhood helped me give this advice with a much softer tone. I get it, mom and dad. And I feel your pain (and exhaustion).

Pacifiers – I missed that thing so much. So, so much. Oh man I missed that thing when it had to go. I think I needed one myself when the time came to get rid of it.

As for the well-rounded, healthy meals I recommend offering your child throughout the day – I now understand why there are food shortages in some parts of the world. It’s because all that food is currently on the floor of my kitchen. Where my son threw it. I get it. And I’m here to help you find tricks to make things better. Tried and tested in my own home.

In all seriousness, motherhood has been the most exhausting, challenging, humbling thing I’ve ever experienced. But I can say without a doubt that it’s made me a better doctor for your child. Because helping you get through those everyday challenges is a huge part of what being a pediatrician is all about.

I recently polled some physician mom colleagues to get their take on how motherhood changed them:

• “I am that much more in awe of the composure, patience, faith, resolve my patients' families have, especially considering how chronically sick the kids are that I see, and how too not-infrequently, limited the treatments are. I see my son in every patient. Everything is different. Every heartache is my heartache. Each illness, each story seems to hit home that much harder. I am so so appreciative.”
• “I am much more empathetic and practical in some advice. I think that I am much more emotionally available post having kids and can understand a variety of stresses parents who go through NICU may encounter.”
• “You come to understand that "by the book" is not always what is possible in real life!”
• “I feel like when the kids have a tougher diagnosis - cancer- it hits closer to home and I hold my kids a bit tighter. Likewise, little pearls and tricks that I used help make it more of a village caring mentality for the family which has been lost over the last 30-40 years.”
• “My medical advice is not too different, but I understand the unspoken worry so much better now. So I try to address the emotional stuff first in ways that would not have occurred to me pre-kids. Now I'll directly say things like "you are a good mother even if you need to use formula," or "this lymphadenitis/rectal bleeding/etc is NOT cancer," or "they are not dangerous, but constant viral illnesses all winter TOTALLY SUCK.” I think it has made me a much better pediatrician.”
• “One of my favorite attendings in peds residency told me, as I was a mess after coming back from maternity leave with my first, that a little part of your heart will always be on the outside, dangling like a vulnerable little wisp in the wind that is parenting- and that little wisp makes you so much stronger and so much softer- all for the good....it's so true.”

Happy Mother’s Day, everyone!

8 isn't enough ... life with 9 children

Nine children, ages 3 to 19 years old, make Mother’s Day a pretty special time for Kristy Goodnight. After all, that’s a lot of hugs and kisses to go around ... But when you consider each child has his or her own special needs, life can be amazingly hectic and difficult. And what’s the biggest challenge for the mom of nine? Click to read more.

Dr. Mom: How motherhood changed me as a pediatrician

After completing 24 years of schooling and medical training, you’d think that once I graduated from pediatric residency, I’d know a thing or two about the health of children. And I did. I knew a lot ... Then, I was blessed to have a beautiful son...who decided that I needed to be re-taught a few things about children.

And by a few things, I mean everything. Click to read more.

How being a mom shaped her practice

I am a better pediatrician because I have experienced life as a mom. I know the tears and tiredness of a new mom and so when she cries at the new baby check I can tell her it's normal and she believes me. Click to read more. Click to read more.

The numerous health benefits of breastfeeding cannot be denied. Some of them might be overstated at times but, all in all, I believe that breastfeeding is best.

I know there are times when, for whatever reason, moms cannot or choose not to breastfeed. Fortunately, we have come a long way from the old days of evaporated milk formulas of the 1920s to where formula feeding is a very reasonable alternative for those moms. I believe that families should be properly educated and supported in their feeding decision no matter what it is.

If you chose to formula feed or plan to, you can stop reading now. This is not one of those articles meant to shame someone for their choice. This post is a message in support of moms and families who choose to breastfeed and need a little help to determine if everything is going OK.

“Seven percent is average, over 10 percent I start to get worried.”

Most moms know (or read or were taught) that babies lose weight in their first few days of life. If not, that one week checkup is pretty emotional when they place their babies on the scale and the number is lower than their birth weight. Think about it, a 10-pound baby can drop to as low as 9 pounds and still be considered normal weight loss, but you would certainly worry from the time the baby was weighed until I came in the room to tell you everything is OK.

I have been quoting this 7 percent/10 percent mantra since I started practice. It’s partially wrong, at least for breast fed babies. Why? They can actually lose more and still be normal.

A study released in Pediatrics in December showed that breastfed babies could lose more than 10 percent and still be normal, especially babies born via caesarean section. The graphs enable a pediatrician to look at a baby’s weight loss day-by-day and determine if the weight loss is excessive. The bottoms of the weight loss peak occur on day six for both vaginal and c-section but the peaks occur at 11 percent and 12 percent respectively.

Why does this matter?

Any mom who has had trouble getting their baby to grow on breastmilk knows the pressure to start formula that can be applied by doctor, nurses or family members. While, I don’t believe that having mom give formula when appropriate ruins her chances of breastfeeding, I certainly don’t want to be pushing families to supplement when it isn’t necessary. Therefore, I plan to start implementing these guidelines into my practice so that I can best support breastfeeding moms in their effort to breastfeed.

If you are having a baby and are planning to breastfeed, it might be helpful for you to be aware of them as well.

The anger and subsequent anxiety I felt after hearing about “The Newborn Sleep Book” surprised me. I am not a “crunchy” pediatrician by any means. I have taught families to sleep. This is why the feeling I got in my stomach is unexpected.

The book is written by two pediatricians in New York who happen to be brothers, Lewis and Jonathan Jassey. The premise is that, through proper training, you can space a newborn’s feeds out to every 4 hours, resulting in them being able to sleep through the night. Their recommendations include: allowing them to cry until their scheduled feeding time, using Benadryl^® for sleep disruptions and increasing feeding volumes during the day to enable skipping nighttime feeds. It’s not the fact that they recommend sleep training; it’s their method that I find upsetting.

This goes against everything you are likely to hear from your pediatrician (certainly me), including the American Academy of Pediatrics. The AAP says some newborns feed as often as every 1.5 hours, while others about every 3 hours. The AAP also says breastfed newborns will feed 8-12 or more times per 24 hours once a mom’s milk has come in.

Oh and here’s something else important from the AAP: “If your baby isn't waking on his own during the first few weeks, wake him if 3-4 hours have passed since the last feeding.”

So that’s a group of 62,000 pediatricians’ recommendations who I tend to agree with on most things and two pediatricians who I couldn’t agree with less.  But I’m not finished making my case. Here are 8 myths I found particularly bothersome in the book:

1. MYTH: The authors have “continually researched and practiced (their) method, adjusted, and practiced some more.”

FACT: The best report of their results is this: a “ballpark estimate is that, since we started coaching parents …over 15 years ago, nine out of 10 parents who have followed through have been successful.” My scientific mind is not satisfied and neither should yours. I am not asking for a randomized, double-blind placebo trial, a simple survey would have been better than a “ballpark” estimate.Very few things in medicine have a 95 percent success rate. So, if you have the research, prove it … if not, it would not be that hard to get.

2. MYTH: Their method is the best way to get your child to sleep through the night.

FACT: The results I do see reported in the book are underwhelming. Their testimonials of patients who began to sleep through the night, included children with ages ranging from 6 weeks to 3 months.  A 2010 study in Pediatricsshowed that 37 of 75 babies were sleeping through the night during their third month. If you took testimonials of parents from that study (which are often the best case scenario), I would imagine you would find plenty of babies who would be sleeping through the night just as early as the Jassey families, many with no fancy plan.

3. MYTH: The authors are Ok with saying that their method may not work for everyone.

FACT: They go on to say later, “sleep training is by no means selfish on the part of the parents. In fact, since its benefits to both baby and family are undeniable, we might say that not sleep training…is a more selfish choice.” First of all, “undeniable?” Not so fast. That is still up for debate. I guess everyone has the right to make their own choices, even if they don’t mind making selfish choices, by not sleep training their children. It’s like saying; there really are no dumb questions, unless you ask a dumb question.

4. MYTH: Scheduling, even from a very early age poses no risk to babies.

FACT: Scheduling from birth as they suggest is dangerous and puts babies at risk, period. Not feeding on demand puts moms at risk for lactation failure. Their recommended 8-12 feedings (for 1-2 days) on demand is not enough for many moms to establish good milk supply. Ask any lactation consultant or pediatrician who understands milk production and they will either laugh or cry at the suggestion that scheduling this early will not affect milk production. In addition, infrequent feeding places babies at risk for increased weight loss and more severe jaundice, which requires further treatment and testing. If you are my patient, please do not schedule your baby from birth!

5. FACT: Crying babies are not all hungry (I actually agree with them, up to a  point …)

MYTH: You should never feed a baby before the time you have scheduled for them.

FACT: The authors state that our first response to a crying baby should not always be to feed them (again, I agree). However, I feel that we can go through our usual steps to comfort them (change diaper, pacifier (if a family chooses), rocking, etc.) and if they do not work, it is reasonable to attempt to feed.

6. MYTH: The authors state that they do not endorse formula feeding over breastfeeding.

FACT: Their method involves careful measuring of volume to ensure your baby gets enough each day don’t “have” to feed at night. Breast feeding simply does not work this way. A breastfeeding mom can’t simply feed a little bit longer… when the breasts are empty, they’re empty. So, while they may not endorse formula feeding, their method could push families toward formula feeding.

7. MYTH: If your baby’s sleep is disrupted for any reason (teething, vaccines, etc.), a combination of Tylenol^®, Benadryl^® and Motrin^® will help to “reset their clock.”

FACT: Uhhh, not for my patients. If your baby is fussy and you think it might be pain from teething, I am Ok with giving a dose of Tylenol or Motrin, but not along with Benadryl. The benefit is slim and the risk of an adverse event (whether appropriately or inappropriately dosed) is too high. Of course, they also mention using teething gels and you should know how I feel about them. There is no reason to treat a normal developmental stage with medicine.

8. MYTH: Feeding your child on their schedule means they will not “become hungry at inconvenient times-like 2 a.m.”

FACT: Parenting is about facing inconveniences. are ways to help your child fit into your life better than others, the very premise of this statement offends me. I’m sorry if your little baby woke up and tried to bother you at night for something to eat. I hope it wasn’t too much of an inconvenience.

The authors do address a concern in their book. It happens to be about co-sleeping, but that’s not important to them:

“We are inherently suspicious of any parenting technique that is so obviously weighted to the parents’ wants over the potential benefits to the child.”

Huh? Me too. This is why I would never recommend their book to my parents.

When deciding about starting a medication as a breastfeeding mother, here are some questions that need to be considered:

1. Has the medication been studied in humans or other mammals?

2. How important is the medication to the mother?  For example, what would happen if the mother did not take the medicine?

Clearly if something is well studied, safe and very important for mom, go for it. If something has been shown to be unsafe and not important, then skip it. In my mind, everything I see is a gray area. If you are not impressed with the helpfulness of this “brilliant” analysis, here are some resources you can use:

1. Your pediatrician or obstetrician. I don’t memorize all the possible drugs, but I do know where to look them up.
2. Infant Risk -Dr. Hale from Texas Tech is one of the national leaders in medication use during pregnancy and while breastfeeding.
3. LactMed –The National Library of Medicine’s Drug and Lactation Database

A Special Consideration: Anti-Depressant and Anti-Anxiety Medications

Because of the relatively small number of breastfeeding mothers on anti-depressants, they are still mostly unstudied. Many have been found to enter the bloodstream at less than 2 percent of the dose (adjusted for the babies weight), but some do reach higher levels (near 10 percent).

Here are some of the ones that enter at higher levels:

• Buproprion
• Fluoxetine
• Lithium
• Venlafaxine
• Diazepam
• Citalopram
• Lamotrigine

Even though we know this, we still don’t know the effects of the medication on the baby is in many ways. The AAP statement highlights the fact that these medications tend to have a build up over time. It is important to note also that baby’s kidneys and liver function (the primary way the we get rid of medications) are not fully mature. Because of this, I evaluate each mother/baby combination by these 3 criteria:

• Benefits of breastfeeding
• Risk of the medication
• Risks of mom’s depression on the child

In summary, I believe we should use caution with all medications with breastfeeding mothers.  If you are breastfeeding, please consult with your pediatrician or obstetrician prior to taking any medication.