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Answers to Your Breastfeeding Questions A Q & A Forum with Anne Smith
Anne Smith, BA, IBCLC, has been in the business of helping mothers breastfed successfully for more than 20 years. Not only is Anne an International Board Certified Lactation Consultant, but she is also a certified La Leche League Leader and mother of six breastfed children! And yes, she has experienced just about everything first hand - cracked nipples, mastitis, engorgement, colic, slow weight gain, jaundice...you name it. Anne has gained a lot of experience in various areas of lactation over the years. She has led group support meetings, taught breastfeeding classes, trained breastfeeding peer counselors to work with low-income mothers, worked one-on-one with mothers to solve breastfeeding problems, held breastfeeding workshops for health professionals, and taught OB, Pediatric and Family Practice residents at Bowman Gray School of Medicine. Anne's also runs Breastfeeding Basics (www.breastfeedingbasics.com) a Web site where you can find great breastfeeding information and products, including Medela pumps and pump accessories. Anne also answers breastfeeding questions online at Breastfeeding Basics. Anne's Articles: Starting Solids: Waiting Is Worth It Caregiver’s Guide to the Breastfed Baby Returning to Work or School Breastfeeding and Birth Control Nursing Discreetly Oversupply: Too Much Milk Spitting Up: Is it Reflux? Nursing Tips for the Large Breasted Mother Relactation and Adoptive Nursing Teething and Biting Nursing Strike Breast Infections and Plugged Ducts Night Waking: Or, Will I Ever Get a Good Night’s Sleep Again? Increasing Your Milk Supply Jaundice Waking A Sleepy Baby Annes Q & A: If I have a cup of coffee, when does the caffeine enter my milk and how long before it's gone? How can I get my baby to feed from a bottle again? Milk supply has dwindled since returning to work, help! Having nipple pain, but don't think it's thrush - what could it be? Baby sleeps through the night, and I wake up engorged! Baby is fussy, colicky and not a very good nurser - will he outgrow this?
If I have a cup of coffee, when does the caffeine enter my milk and how long before it's gone?
NAME: Alison BABY'S NAME: Dylan Scott BABY'S AGE: 4 weeks BIRTH WEIGHT: 8lbs, 12oz CURRENT WEIGHT: 10lbs, 6oz How long does it take for what you eat to affect your breastmilk? For instance, if I have a cup of caffeinated coffee in the morning, when will the caffeine enter my milk and how long before it is gone?	Hi Alison, It is impossible to make a general statement about how long specific foods take to enter your breastmilk. It varies with each individual food, and each mother absorbs, metabolizes and excretes substances at different levels. This is true of caffeine as well, but it has been studied so thoroughly that we have more information about it than we do about some other substances. Generally speaking, caffeine will peak in your milk about an hour after ingestion. Its half life (the time it takes for one half of it to completely leave your milk) varies from 80 hours in a newborn to about 2 ½ hours in a six month old. It takes four or five half-lives for a drug to be completely eliminated, so caffeine stays in the baby’s system for quite a long time. As with all drugs, newborns and preemies take longer to eliminate caffeine from their body than older babies because their digestive systems are less mature. The good news is that although caffeine gets into your milk quickly and takes a long time to excrete, it rarely causes problems for breastfed babies. Most studies have found the levels in newborns to be very small, and often undetectable. Each cup of coffee contains about 100-150 mg of caffeine. The amount of caffeine in five cups of coffee per day (less than 750 ml) has not been shown to cause problems for most mothers and babies. Mothers who consume 8 or 9 cups a day, or more than 750 ml have sometimes noticed that their babies are fussy and don’t sleep well. If you think your baby is sensitive to caffeine, try cutting down over the course of a week by substituting caffeine free beverages for what you usually drink. Abrupt withdrawal from caffeine can cause headaches. Caffeine in moderation rarely causes any problem for babies, but be more conservative if your baby is a newborn or is premature. If you are trying to limit your caffeine intake, remember that it can also be found in tea, soda, and certain medications such as pain relievers, stimulants, and weight control aids.

How can I get my baby to feed from a bottle again?
NAME: Kristen BABY'S NAME: Katelyn BABY'S AGE: 10 weeks BIRTH WEIGHT: 8lbs, 14oz CURRENT WEIGHT: 13lbs, 4oz I am breastfeeding and my husband tries to give Katelyn a bottle every day or so of pumped breast milk. She has always done fine going back and forth between the bottle and the breast. My husband has been extremely busy at work recently and has not been as consistent with feeding her. The past two days she has cried and not wanted to feed from a bottle. This is a problem because I return to work two weeks from today and my husband will be at home with Katelyn and will need to feed her the breast milk from a bottle. Any suggestions?	Hi Kristen, Your experience illustrates the importance of continuing to offer a bottle on a regular basis once it has been introduced. It doesn’t have to be every day, but if you let more than a few days go by, you may have to start from scratch with getting her to take it because older babies can get very set in their ways. Here are some tips to use whether introducing bottles for the first time, or re-introducing them to a baby who’s on a "bottle strike": -Try offering the bottle when your baby isn’t starving. This may seem illogical, but when a baby is frantically hungry, she is going to be in no mood to try something new. She just wants to nurse. - Your baby associates your smell and touch with nursing, and may insist on the real thing if you try to give her a bottle. You may have to leave the room entirely in order for the effort to be successful. - Many babies associate the cradle hold (where they are cuddled against the breast) with nursing, and will refuse to accept the bottle as a substitute if held in this position. Although some babies will accept a bottle more readily in the cradle hold, most will do better if you prop them up on your knees or in an infant seat, and make eye contact while feeding them. -You don’t have to substitute a bottle-feeding for an entire nursing. In the beginning, have dad try giving an ounce or two in the evening while your supply is lowest and you are the most in need of a break. Leave the room. Take a hot bath. Hope that it works. -Some babies will take the bottle more readily if you move rhythmically while walking, swaying, rocking and/or talking to them to distract them. - Try feeding her when she is half asleep. -Try different nipples. Some babies prefer a slow flow nipple, some a faster flow. In general, orthodontic nipples tend to have a slower flow, which may be an advantage in a newborn, but a disadvantage in an older, more impatient baby. -Make sure the nipple isn’t cold when you offer it. Many babies couldn’t care less if the milk you give them is cold (and it doesn’t cause digestive problems – that’s an old wife’s tale) but they don’t like the feel of a cold rubber nipple in their mouth. Run it under warm water before you offer it. - Some babies with discerning tastes will refuse to take milk in a bottle, but will accept apple juice. It’s almost as though they know that milk is supposed to come from breasts, and they won’t take it any other way. Breastmilk is quite a bit sweeter than formula – I have heard a toddler describe it as tasting like ‘melted ice cream.’ If you can overcome your squeamishness, taste it sometime. It really does taste better than cow’s milk or formula. Most babies will take breastmilk more readily than they will take formula, but if you have a baby who is really picky, try offering a little bit of apple juice. If you can get her to take a few sips, try mixing milk with the juice a teaspoon at a time until you have more milk than juice. I’m not talking about a lot of juice, because babies under six months shouldn’t really have juice because it’s sweet and they tend to suck it down quickly. It’s not a good idea to fill them up on empty calories, but we’re talking about a very small amount here – maybe ½ to 1 ounce, and only until she accepts the bottle. -When offering the bottle, tickle the baby’s lips gently with the nipple until she opens her mouth and explores the nipple. Don’t try to force the nipple in her mouth. - If your baby is older than a month or two when you offer the bottle, and she refuses it completely, try cup feeding. Many older babies bypass the bottle completely during separations from mom and do well with the cup. As long as they are nursing most of the time, their sucking needs will be met. I wish you luck. Since you have a couple of weeks to work on this, I’m sure you’ll have her taking the milk from your husband one way or the other before you return to work.

Milk supply has dwindled since returning to work, help!
NAME: Tamara BABY'S NAME: Natan BABY'S AGE: 3 months BIRTH WEIGHT: 7lbs, 1oz CURRENT WEIGHT: 10lbs, 8oz : I returned to work (as a physician) two weeks ago and found my milk supply dwindle to almost nothing. In a matter of two days, I went from pumping 4- 6 ounces to 1 - 2 ounces/pumping session. It's incredibly discouraging! I've worked so hard to increase my supply before returning, because I was nervous I wouldn't be able to pump enough for him, but I didn't realize that stress can contribute this much to a poor supply! Can it really? I drink a lot of fluids, try to pump twice during the day at work (my hours are from around 8 - 6) and when home, try to breastfeed him as much as he wants. Should I pump for volume at work, or more frequently? Which would help my supply more? Any other hints/ suggestions? Help!	Hi Tamara, It is very common for mothers who return to work to find that their milk supply decreases, although the drop is not always as dramatic as the one you experienced. The first question I would ask is what kind of pump are you using? There is a huge difference in the results you get with a manual or small electric/battery type pump and a high quality double pump like the Lactina, Pump In Style, or Purely Yours. If you are going to be pumping regularly, or if time is an important consideration, you really need to be double pumping with a larger, more efficient professional or hospital grade pump. Double pumping is an important feature. Not only does it cut your pumping time in half (from 20-30 minutes with single pumping) to 10-15 minutes or less, but your prolaction levels are higher when you double pump, so you actually produce more milk in less time. Assuming that you are using a good double pump, let’s talk about what else you can do to boost your production. First, there is no pump on the market at any price that is as good at removing milk as a healthy baby who is nursing well. When you’re at home, you tend to do little "snack" nursings throughout the day, and when you’re at work, you’re on a schedule and only empty your breasts at specific intervals, usually several hours apart, so you don’t get the same stimulation. If you are separated from your baby from 8-6, that’s a ten hour stretch. Pumping twice during that time means that your breasts are only getting emptied every five hours. If your baby is sleeping a long stretch at night (over four hours), then chances are good that you are only emptying your breasts 5 or 6 times a day. If you nurse in the morning, pump twice at work, nurse when you get home, again at bedtime, and once during the night, that’s only six times in 24 hours. For a young baby who isn’t receiving any solid foods, it is hard to maintain an adequate supply unless the breasts are being stimulated eight times or more in 24 hours. That isn’t true for every mother, but it is for most. If at all possible, try to get in an extra pumping session at work. Pumping for ten minutes three times a day will do more to build your supply than pumping for twenty minutes twice a day. Try to relax while you are pumping. There is a tendency to stare at the bottles and tense up while you’re thinking "Oh my gosh – I’ve been pumping for five minutes and only have an ounce! I’ll never be able to pump enough!" Putting this kind of pressure on yourself only makes you tense and keeps your milk from letting down fully. If you’ve been pumping for several minutes and only a trickle or drops are coming out, stop pumping. Try stretching, deep breathing, getting a drink of water, massaging your breast, listening to soft music, or anything at all that helps you relax. Then try pumping again. If your milk doesn’t let down, you can sit there all day and not get much out, even if the milk is in there. It’s very important to try to relax, and breaking the pumping session up into smaller increments may help accomplish this. Here are some more tips for increasing your supply: - Pump after feedings for five minutes, or on the other side when your baby takes one breast at a feedings (your supply will be more plentiful in the mornings). -Take care of yourself. Try to eat well and drink enough fluids. You don’t need to force fluids-just drink to thirst. If you are drinking enough to keep your urine clear, and you aren’t constipated, then you’re probably getting plenty. Your diet doesn’t have to be perfect, but you do need to eat enough to keep yourself from being tired all the time. It is easy to get so overwhelmed with baby care and work that you forget to eat and drink enough. -There are certain food supplements as well as prescription medications that may increase your milk supply. Many herbal supplements have been used for many years to increase milk production, with the most popular being Fenugreek, Blessed Thistle, and Red Raspberry. Brewers Yeast (containing B vitamins) is another commonly recommended treatment for low milk supply. I usually recommend that mothers try Fenugreek capsules (2-3 capsules taken 3 times daily) along with Blessed Thistle tablets (same dosage). You many want to add BrewersYeast tablets (3 tablets taken with meals, 3 times per day) and Red Raspberry tea or capsules several times each day. I know that seems like a lot of capsules to take, but if you don’t want to take them all, the Fenugreek seems to be the most effective. Prescription medications such as Reglan and Domperidone are usually reserved for moms with medical concerns such as babies who aren’t gaining weight well, and not for mothers who have normal supplies which drop when they return to work. -If you have tried everything that you can to increase your supply and are still unable to produce enough during the workday for your baby to have only breastmilk the next day, you may decide to combine breastmilk and formula feedings. Many working mothers find that this option is less stressful for them, and it is important to remember that any amount of breastmilk provides important benefits, and you can still nurse when you are together. Maintaining a milk supply for a baby when you are separated for many hours a day is always challenging and seldom easy. It’s a real labor of love, and provides many advantages for both of you, so it’s definitely worth the effort.

Having nipple pain, but don't think it's thrush - what could it be?
NAME: Tracie BABY'S NAME: Caleb BABY'S AGE: 11 months BIRTH WEIGHT: 7lbs, 5oz CURRENT WEIGHT: 19 lbs I have been experiencing nipple pain (on both sides but it is worse on the right side) for a few weeks now and actually have a small sore on the tip of my right nipple. I have previously had thrush on my nipples that caused a similar pain, that was easily cured by application of liquid nystatin for 2-3 days. I have tried using nystatin this time also but it does not seem to make a dent in the problem. (Yes I was sure to use it on my baby's mouth also, along with acidopholous for both of us 3-4 times daily.) I have come to the conclusion that this time it isn't thrush, but I am at a loss for what it could be, and it is EXTREMELY painful at times. Is there something else I am not thinking of, or have you ever heard of a really resistant case of thrush? I don't know what to do about this, and I plan on nursing for a couple more years so I need a solution...any suggestions? Thank you, Tracie P.S. Nothing has changed in the way he latches on, and he has had his teeth for several months and they've never bothered me before, so I don't think that is the problem, however I do have small tooth shaped calluses at the edge of my areola.	Hi Tracie, Chances are very good that what you are experiencing is indeed a resistant case of yeast. Yeast infections are extremely difficult to clear up, and it usually takes several weeks of treatment to eradicate it completely. It’s kind of like taking an antibiotic for a bacterial infection: you feel better within a day or two of taking the drug, but if you don’t continue taking it for the full course of treatment, you kill off the weaker bacteria and the stronger bacteria survive and come back to cause problems later. The same thing is true of yeast. I would be very surprised if using nystatin for a few days had cleared up your infection. For one thing, nystatin often doesn’t work well because so many resistant strains of yeasts have developed over the past few years. For another, it usually takes at least a couple of weeks of treatment with any antifungal agent to completely clear up the infection. The fact that you are experiencing so much pain and have sores on your nipples makes me think that you are still dealing with the yeast, because there just aren’t many things that can cause those symptoms when you’re nursing an older baby. It’s unlikely that teething would cause this kind of soreness. You need to treat yeast aggressively or it can drag on for months and months. There is a lot of good information on treating yeast on Breastfeeding.com, including a Q&A session on this topic that I did last month. I also have an article on my website all about yeast, with lots of references that you can share with your doctor as you work out a treatment plan. I hope that you will follow up on this promptly because without proper treatment, the yeast will continue to grow and probably will eventually invade your milk ducts, if that hasn’t happened already. It’s much easier to treat when it’s confined to the surface of the nipple, so try to act quickly to prevent intra-ductal yeast from becoming a problem.

Baby sleeps through the night, and I wake up engorged!
NAME: Jennifer BABY'S NAME: Haley BABY'S AGE: 5 1/2 months BIRTH WEIGHT: 7lbs, 5oz CURRENT WEIGHT: 16lbs My baby sleeps through the night. About 10 hours. I wake up engorged every morning. This has been happening for quite a while. Will my milk ever adjust to this or could this be just normal for me? I can't seem to find information on this. Your help would be greatly appreciated. Thank you!	Hi Jennifer, Most moms would love to have your problem! Having a whole 10 hour sleep stretch is such a luxury, and quite unusual for a breastfed baby. I’m not surprised that you’re having trouble with engorgement, though. Most babies start sleeping through the night by gradually going longer stretches, say from 2-3 hours to 4-5 hours and then up to 6-8 hours over a period of months. The human body is amazing adaptable, and if the transition is made gradually, your breasts respond to the lack of stimulation by making less milk, so you experience less fullness. I don’t know how long your baby has been sleeping this long at night, or how long it took to get to this point. Your body should adjust with time, but it’s impossible to say how long that will take because every mother is so different. Just as some moms leak a lot and some hardly at all, some will experience more engorgement and fullness than others. There is really no way to prevent the engorgement or make it go away faster. Other than the fact that you’re uncomfortable, the concern would be that the engorgement could lead to plugged ducts and/or mastitis. If that were going to happen, it probably would have occurred by now. If you feel that you are developing plugged ducts, it would be a good idea to apply heat and express some milk to relieve the pressure and unclog the ducts. I wouldn’t do that unless you were really sore, though, because when you remove the milk, you’re sending your body the signal to make more. Your body should adjust with time, but you may be one of those moms who always experiences some degree of fullness when you go long stretches without nursing. Nearly all mothers find that the longer they nurse, the softer their breasts feel and the longer they can go without becoming engorged. I hope that things settle down for you soon.

Baby is fussy, colicky and not a very good nurser - will he outgrow this?
NAME: Holly BABY'S NAME: Dillon BABY'S AGE: 14 weeks BIRTH WEIGHT: 8lbs, 6oz CURRENT WEIGHT: 14lbs Now at 14 weeks Dillon is still not the best at breastfeeding, and I am about to give up and go for bottlefeeding. My intentions were to breastfeed for six months. We had a rough start from the beginning, and he still isn't the best at it, and he is a bit of a fussy/colicky baby. Will he outgrow this, and I should just stick with it? Any advice would be great. At times he even cries as loud and ferocious as he can when I lay him in my arms to breastfeed. His dad then has to calm him down before I can continue and sometimes that doesn't work. Help!	Hi Holly, It sounds like you are really frustrated with this whole nursing thing, and I don’t blame you. It seems so unfair that something so natural can be so complicated at the same time. Having a fussy, colicky, unhappy baby is one of the most frustrating things a new mother can experience. When your baby is unhappy or in pain, you just want to make it better. Sometimes nothing you do seems to work, even when you’ve done all the "right" things: nursing, rocking, diapering, walking, patting, singing, etc. After hundreds of years, nobody really knows exactly what causes colic or how to cure it. All we know is that some normal, healthy babies will cry inconsolably for several hours a day while passing gas, and nothing the parents do seems to help. The typical colicky baby is gaining weight appropriately. If he isn’t, then he may be crying not because of colic, but because he’s hungry, and the issue of how to increase milk supply or establish more effective nursing patterns needs to be addressed. There is a tendency for parents (and doctors as well) to want to blame breastfeeding whenever something goes wrong - if the baby spits up, is gassy, fusses, has loose stools, etc., then everyone starts going: "Hmmm. Maybe it's the milk...maybe I ate something that's upsetting his stomach...maybe she's allergic to something in my diet"...and so on. It's human nature to try to find the cause if your baby is not feeling well, because then you can "fix" the problem. Unfortunately, breastmilk is a convenient scapegoat. The facts are this: nothing is as good for babies as human milk. It is easier to digest than formula, and contains all kinds of protective antibodies that formula just doesn't have. A baby who is colicky will do better on mother's milk than on formula. Sometimes babies just have sensitive digestive systems and it takes a while for them to mature. The thing to keep in mind is that babies who are more sensitive than average need breastmilk even more than the average baby. Often when mothers switch to formula out of frustration, they trade one set of problems for another. Yes, the baby may sleep longer stretches, but the downside may be more allergies and ear infections. There are two things that I would recommend in your situation: find a Lactation Consultant or La Leche League Leader in your area who can help you assess your individual situation. Maybe your little guy is getting too much foremilk and not enough hindmilk. Maybe you have a problem with over or under supply. It’s also possible (but unlikely) that your baby is sensitive to the proteins found in dairy products, and eliminating them from your diet would help. These are issues that can be addressed with assessment and recommendations from a knowledgeable breastfeeding counselor. The second thing I would recommend is getting hold of a copy of Dr.William Sears’s wonderful book "The Fussy Baby." He talks about "high need" babies and how to cope with them. He addresses the topic of colic in great detail, and gives lots of helpful suggestions that will make you feel better about your situation. I hope you will hang in there because I can promise you, it does get easier, and the rewards of nursing your baby are well worth the effort.