What does a breastfeeding mother and baby need besides each other? Clearly, they need time and proximity so they can adjust their relationship from a continuous but unconscious provision of warmth, comfort and nutrition by mother of baby to a deliberate but more intermittent provision of those same requirements for baby by the mother. Mother needs the support of those around her to meet her physical and emotional needs while she meets those of the new baby. And this process takes time to develop its rhythm. Like new dancing partners, the dyad must become comfortable and intuitive in their actions, developing trust and coordination over time.
But — what if a separation must occur. Mom can no longer be ever-present to meet her baby’s needs. Or what if baby or mother has a physical issue that affects milk supply or delivery? How can we provide a substitute for both mom and baby that doesn’t undermine the breastfeeding relationship? The market steps in to offer its solutions: bottles, pacifiers and breast pumps! These tools offer and purport to be a temporary solution to bridge the separation on a short term basis, but often present their own challenges to mother and baby.
So, how do we select when presented these “solutions?” First, understand the basic physiology of breastfeeding. How do mothers make and release milk? How do babies obtain that milk? What is the biology that we are trying to mimic? What are the properties of the man-made materials that we use to create these tools? Over the years, inquiring minds have looked at various products on the market to try to determine how these products work and to what degree they either simulate breastfeeding or offer less interference with breastfeeding when used. The problem is, most of the methods used to test products don’t truly match what a baby does when they use the products. Ultrasound studies may show the mechanics baby uses on a bottle, for instance, but can’t really measure the baby’s adaptation to the materials or how the baby changes flow rates by altering the quality or actions used during sucking. Only a very sophisticated real-time system using pressure gauges, ultrasound and sequential weight checks can adequately assess the way a bottle performs for a particular baby. And even that can’t determine how a baby is adapting and accommodating to the bottle.
Also, keep in mind that the way a bottle is offered and the position that the baby is held affects the way baby accepts the bottle and the way it works. Babies who are breastfeeding well use their tongues to create vacuum and control the flow of the breast. When babies are held on their backs to feed from the bottle, gravity may push the flow and cause baby to react by altering the way they use their tongue.
Pacifiers
Some fairly good research has found that pacifiers introduced after the first two weeks and limited to less than 2 hours use during the day do not appear to inhibit milk supply or shorten breastfeeding. In this study, a one-piece pacifier with a rounded nipple and slight flange at the base was used for all babies in the study.(1) In this study, all babies were healthy babies with no identified risk factors such as tongue-tie etc. Early introduction of pacifiers may interfere with baby’s learning curve where he identifies and correlates sucking and swallowing with latching to the breast. Pacifiers are made of materials much firmer than mother’s breasts and do not conform to the baby’s palate. This imprinting period can last up to 6 weeks. An analogy I have sometimes used is this: introducing a pacifier is like giving a young teen porn – it is artificial, highly stimulating, and does not resemble the real shape, feel or action of the real thing. Ear, nose and throat specialists who work with babies with tongue and lip-ties have noted that babies who have used pacifiers a great deal can have issues learning how to open widely and actively extend the tongue to latch onto the breast. If possible, delay pacifiers until they are absolutely necessary, after comfortable and effective breastfeeding is established, and then limit use to less than two hours daily. Avoid orthodontic, flat or bulbous pacifiers.
A skilled IBCLC can assess a baby’s sucking technique, evaluate suck strength and make recommendations for supplementation methods if needed. They can offer suggestions to help the nursing couple to address and overcome any issues encountered. They can also evaluate mom’s supply and make recommendations for techniques, equipment and supplements as needed. They can communicate with other healthcare providers to coordinate breastfeeding and family-friendly care.
Bottles
The research that has been done on bottles includes direct ultrasound and indirect flow studies using a pump setup to mimic the vacuum levels babies use on bottles.(2) Some bottles will deliver nearly an ounce in a minute! This fast of a flow rate will cause a baby to take too much at a time from a bottle, may cause gassiness and fussiness and spitting up. Some bottles will deliver a fast rate of flow if the baby bites on the nipple. When babies must use a bottle and the flow rate or method of obtaining the milk (compression instead of sucking) varies from what is normal during breastfeeding, it can cause bottle or breast rejection. Bottles that drip when held sideways do not necessarily flow fast when baby is sucking. And, bottles that don’t drip, are not necessarily slow flowing when used by the baby. Generally, 5 ounce Newborn Dr. Brown’s bottles with regular size neck, not wide-mouthed, Special Needs Feeders, used with the small line lined up with baby’s nose, Calma feeders, and Munchkin Latch bottle are considered slow-flow, non-compression bottles. Bottles not recommended include Avent, Tommee-Tippee, Momma original, Evenflo original, and many others. This list is subject to change, however, as manufacturers constantly change or quit making products over time. The best way to test a bottle is to buy one only, try squeezing the nipple where baby’s gums would go to check for compression, and offer to baby.
When bottles are recommended for supplementation, it is a good idea to have a lactation consultation to evaluate the baby’s suck and mother’s supply. This can help in choosing the right bottle or another method for supplementation that can help preserve the breastfeeding relationship.
Check out my hand-out on using a bottle under resources.
Pumps
When I started nursing my first baby in the early 70’s, and needed to go back to school, the best you could do for a breast pump was one of these: This thing was hard to clean and could only hold maybe an ounce. Needless to say, not too many moms used them for very long or with much success. By my second child,
this kind of pump was available. A little better, still not great. Fortunately, I was able to delay returning to work until he was over a year and I didn’t need to pump. By my third, the first electric piston pumps were available in hospitals. They looked like this: For the everyday working mom, manual pumps were still the only option. By 1987, when I opened the first Outpatient Lactation Service in Nashville, heavy duty hospital pumps were available for rental. Battery pumps also became available, like this:but weren’t super comfortable or effective. By 1989, along came a lighter weight rental pump This pump could do both breasts at once and was portable! By mid-1990’s the first Pump In Style, a lightweight single user pump that could double pump was available for purchase. Medela continued pioneering work in the lab, building on the work of Egnell and Whittlestone, trying to design a pump that would be efficient, effective and yet portable and quiet. Variable speed and vacuum pressures were investigated and the Symphony was invented in 2003.
Medela as well as many other manufacturers have since built and sold breast pumps of various sizes, colors and technologies. There is a huge market of mothers who realize that breast milk is what babies need but have to be away from their babies and need to provide that milk when they are apart.
So how do you choose an effective pump that’s right for you? First of all, look at your need. Have you established a good milk supply with a healthy nursing baby? Milk supply peaks at about 4 weeks postpartum and regulates at about 8 weeks. Minimum requirements for babies from 1-6 months is about 750 ml per day. That’s about 25 oz. Research has shown that a breast pump needs to be able to remove at least 70% of mom’s available supply to maintain production. More complete removal can increase production over time. Less complete removal will decrease production. This is a normal process and is how breastfeeding works when a baby nurses. If a mom only needs to be away from her baby on an occasional basis, any pump that gives her some relief and removes some milk is useful, as when she and baby are together again, the baby can remove the extra milk left behind. Or if a mom is very full and needs some extra relief, a simple vacuum “pump” (really more of a milk catcher than an actual pump) such as the Haaka is inexpensive and can do an adequate job for many moms. The Harmony pump by Medela, is a simple single manual pump that can be used. Many moms find this pump especially useful as an emergency pump when they are traveling or away from their baby because it is quiet, light and portable. For moms returning to work and needing to pump quickly, Medela, Spectra, Ameda and many other companies sell pumps. You can look at Amazon reviews. Here is the FDA’s review of breast pumps.
If you have a low milk supply, a baby in the NICU or you are in the hospital, a hospital rental-grade breast pump is the best type of pump for helping increase supply. The pump needs to be able to stimulate a let-down and then apply enough vacuum to empty your breasts quickly when you have a let-down. The flanges should fit your nipple. Medela.com has information on choosing right sizes of flanges. There are YouTube videos available and several blogs. Here’s one: http://www.medelabreastfeedingus.com/tips-and-solutions/13/choosing-a-correctly-fitted-breastshield. Look into hand-on pumping, do hand-expression after milk flow has stopped, and gentle breast massage before pumping. Some moms find that using coconut oil (if you are not allergic) inside the breast flanges improves comfort. In addition, hands-on pumping can help improve milk-removal, thus improving supply. http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
What if you don’t feel let-down? Milk squirting or fast-dripping into the pump flange is the best sign of let-down. But constant staring at the bottles can inhibit let-down! Playing music, drinking something warm, looking at a picture of your baby and even letting the baby nurse on one breast while pumping on the other, if possible, can help your body learn to respond with let-down. Let-down is essential as the breast pushes the milk out with tiny muscles around the milk collection areas towards the nipple. Vacuum created by the baby or the pump stimulates your brain to release the hormones that cause the muscles to contract and the hormone that causes milk to be produced for the next feeding session.
Some hints for effective pumping include: warming the breasts before pumping (studies have shown up to 50% more milk obtained that way), make sure your pump flanges fit your breast (consider new Personal Fit flanges by Medela, switching the pump rhythm from “stimulation mode” to “expression mode” within 60 seconds to take advantage of the hormone surge and get milk out more quickly, increasing the sucking pressure to optimal levels (maximum comfort vacuum is best). Using soft silicone flanges can increase compression of the breast which can sometimes slow drainage of the breast. Duckbill style valves on the bottom of pumping flanges can fail or gradually decrease the vacuum the pump is creating which also can affect supply. The pump should cycle about 60 times a minute during expression phase and twice that during stimulation phase.
Pumping is one of those things that moms do to get by. It is never the best option, but in some cases it is the ONLY option a mom has to provide her milk for a baby who can’t yet do the job or when mom and baby are separated by employment or illness. It is hard work for many moms, but it is something only YOU can do, as your milk is the milk best suited for YOUR baby!
(1)Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding? Jenik AG, Vain NE, Gorestein AN, Jacobi NE, Pacifier and Breastfeeding Trial Group J Pediatr. 2009;155:350-354 (2) Comparison of Flow Rates between Commercial Bottles Karen Gromada, IBCLC unpublished communication.