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Triple Feeding

Here is a made-up, but very typical, case-study.

Jo and her partner Sky had their baby a couple of weeks early, by cesarean. Because of the cesarean, Jo’s milk took a few days to “come in”. It’s very common, after the extra stress of surgery, for the body to take a little extra time to start producing mature milk.

And the baby, named Louis, has had trouble getting on the breast well, and emptying the breast effectively, because he’s a couple of weeks early, also a common problem. So he lost a little more than 10% of his birth weight in the first three days.

The maternity doctor recommended that Louis receive some formula to supplement his feeds at the breast. In order to make sure he was getting all the breastmilk possible, Jo would put him to the breast first, at each feed, and then top him up with 1-2 ounces of formula. And in order to make sure her breasts were completely emptied, Jo would pump after each feed for 10-15 minutes.

So Jo and Louis left the hospital on Day 3 and went home Triple Feeding

1. Baby to breast
2. Supplement baby with bottle
3. Pump to empty breasts

Jo found that every feed took over an hour, even if her partner Sky fed Louis the bottle while she pumped. Then Louis would sleep for a couple of hours and then wake up to start all over again. It was exhausting.

At Louis’ one-week doctor visit, he had gained only two ounces since leaving the hospital. Just barely enough. (Babies are supposed to gain an ounce a day, or about half-a-pound a week.) The doctor suggested Jo give him at least 2 ounces of supplement after every feed. Jo and her partner Sky went home determined to get Louis to gain weight well. And they did! The following week, Louis had gained 9 ounces! The doctor was happy and told them to keep doing what they were doing – it was clearly working.

But it wasn’t working. Jo and Sky were on a treadmill of feeding, pumping, and washing bottles, with little naps in between. It was taking both of them to manage and Sky had to go back to work in a couple of weeks. Jo broke down sobbing at the thought of coping with this all day alone. This was when they made an appointment to see a lactation specialist.

Reach out for help!

I see many little families like this one. They have overcome the hurdle of getting their baby to gain weight, but they are stuck in an unsustainable pattern of feeding. Much of what I do when I meet with them is help them figure out a way to feed their baby more sustainably, while making sure their baby continues to gain weight at a good rate.

For some families, I can help them wean from pumping and supplementing. Some will have to continue supplementing, but can stop pumping, and some may decide to pump exclusively. Some may decide to move to exclusive formula feeding. There are as many solutions to the problem of feeding a baby as there are families. It’s a matter of  helping them identify their goals, and helping them understand the pros and cons of various strategies.

What is true for everyone who goes through a period of Triple Feeding, is that they need support and guidance finding a sustainable way to feed their baby. If you are in the situation I described above, please ask your care provider for more help, and perhaps see a lactation professional as well. La Leche League also provides excellent help. The Victoria Breastfeeding Cafe on Facebook is a great way to get peer support.

Remember that, no matter how small the amount of human milk your baby gets, it is always of value. But your own mental health and comfort are also tremendously important. Feeding your baby, no matter how you do it, can be comfortable, manageable, and, dare I say it, even enjoyable!

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A Breast/Chest Field Trip

Many changes occur in a person’s breast/chest tissue during their pregnancy and after the baby is born. When new parents come to me with breast/chestfeeding difficulties, and I ask them if their nipples are “cracked”, they sometimes are not sure. “I don’t know what my nipples looked like before the baby started to suck on them. Do they look normal now?”

To get a sense of what equipment you are starting out with on your breast/chestfeeding journey, it might be a good idea for you to go on a “Breast/Chest Field Trip” at the end of pregnancy.

(Please note: If you have concerns about your breast health, or if you have had breast surgery or top surgery, some of this may not be relevant to you. Please see your doctor or midwife and consider setting up a prenatal appointment with a Lactation Consultant (IBCLC) to prepare for any challenges you may encounter when breast/chestfeeding your baby.)

1. Take your top and/or bra off and stand in front of a mirror with good lighting.

2. Look at your chest. You may notice:

• Your breasts/chest tissue are bigger than before you got pregnant. Most of the glandular tissue you need to make milk grows during pregnancy. And all the little ducts that are needed to transport the milk grow then too. Some chest/breast tissue grows a lot, and some grows only a little, but they almost all grow some.
• One side is larger that the other. As breasts/chests grow, the difference in size between them (and there is almost always a difference in size) becomes more apparent.
• Your sides are not symmetrical. One nipple may be lower than the other. One may point more to the left, or more to the right. Knowing that your breasts are not symmetrical may help you figure out how to position your baby on your body

3. Look at your nipples. You may notice:

• Your areola (brown or pink part of  around the nipple) has become bigger and darker.
• You may have more visible or darker bumps on the areola. These are sometimes called “Montgomery’s tubercles” but they are more descriptively called Sebaceous Glands of the Areola. They secrete an oily substance that keeps the nipple and areola supple and smells attractive for the baby. The smell helps the baby find the nipple.
• Your nipples may be bigger and darker than before. They may stick out more. The skin may be crinkly (the anatomical term for the crinkles is “rugae”) (These crinkles are not “cracks.” When a baby attaches to the breast too shallowly, and the nipple get pinched, a blood blister may form and then a wound may develop. That is what people mean when they talk about “cracked nipples.”)
• Your nipples may only stick out if they are touched, massaged or get cold. If that is the case, you may have “flat nipples.”
• If your nipples retreat when you compress the areola, you may have “inverted nipples.” This is caused by short connective tissue within the nipple. Check with your doctor or midwife to make sure.
• Inverted or flat nipples make people feel worried about being able to feed their baby. Don’t worry! Babies use the nipple as a guide to tell them where to latch on. Flat and inverted nipples make it a little more difficult for the baby to FIND the nipple, but you are going to be there to help! The baby is supposed to take a big mouthful of tissue, including the nipple and much of the areola, so the size of the nipple or invertedness of the nipple should not matter. Many parents find that after they have been feeding for a few weeks, their nipples stick out and become easy for the baby to find.
• There are gadgets and exercises out there to “fix” inverted nipples. There is no scientific evidence that those gadgets and exercises work. The best way to deal with flat or inverted nipples is to get expert breast/chestfeeding help after your baby is born.

4. Pull gently on your nipples and see how far out they stretch.

• When a baby is connected properly to the breast/chest, the tip of the nipple is all the way at the back of the baby’s mouth – at the soft palate. When I tell pregnant parents this, they imagine that their own little nipple could never reach that far. But nipples and areolas are very stretchy! Check it out!
• A generation or two ago, mothers-to-be were told to “prepare” their nipples by scrubbing them with a rough towel or rubbing them with alcohol! This is no longer recommended. It does nothing to prevent sore nipples, in fact it may damage the skin of the nipples and make them more tender.

5. Try to express a little colostrum. (These directions are given for your right side. Try your left side first if you are left handed!)

• Hold your right breast or chest tissue in your right hand.
• Have your little finger all the way back at your chest wall and your other fingers supporting the weight of the tissue.
• Have your thumb on top. Move your finger and thumb back towards your chest, away from the areola, and then slide them forward, compressing the tissue.
• When you get to the base of the nipple, stop and maintain the pressure for a few seconds.
• Don’t pull on the nipple – that just pinches the ducts closed.
• Imagine there little “grapes” under the skin and you have coax the “juice” out of them!
• Move your hand around so you try all different angles – all different points of the compass.
• You may need to try for several minutes before you see a few drops of colostrum. It takes some time to get the knack.
• Some people see little beads of yellow colostrum on their nipples during the second half of pregnancy. Some see little yellow crusts of dried colostrum. Others don’t see colostrum at all. But almost every pregnant person makes colostrum after about 20 weeks.
• Expressing or leaking a little colostrum does not “waste” any, because you will continue to make it until about 10 days after the baby is born.
• The purpose of expressing colostrum here is just for you to develop a better understanding of how your milk producing glands work. You don’t have to do it. If you express colostrum now, it does not mean that you will make more (or less) colostrum later. If you can’t, it doesn’t mean there isn’t any. It probably just means you haven’t figured out how to do it yet. Try again later, or wait for your baby to figure it out.

6. Look at your breasts/chest again and think about what wonderful “equipment”, what beautiful “packaging” they are for making and delivering milk to your baby!