The Motherwear Breastfeeding Blog

Book review: Eat Well, Lose Weight while Breastfeeding.

Eat Well, Lose Weight, While Breastfeeding (Ballantine Books, 2006), by Eileen Behan, R.D. is an updated version of her 1992 book of the same name. 

While there are a number of features to appreciate about this book, my favorite is Behan's low key and reassuring approach to balancing new motherhood with weight loss.  While she acknowledges the pressure many women feel to "bounce back" quickly to an idea shape after having a baby, she states, "while you are breastfeeding, your primary job is to take care of yourself and your baby."

This book has some wonderful practical advice, including meal plans, nutritional information for nursing mothers, and exercise information.  The final chapter provides advice on eating well after weaning. 

She also does a good job taking on the "500 extra calories per day" guideline for nursing mothers, pointing out that for some women this is far too many calories.  She dispels the myths that there is a long list of foods which need to be avoided during breastfeeding, and that a nursing mother must force herself to drink water.  She encourages mothers not to focus on what they shouldn't eat, but "instead, emphasize all the good foods you can have."  She comments on low carb diets while breastfeeding, sugar substitutes, and fish safety. 

When discussing the research on weight loss and breastfeeding, Behan presents only studies which showed minimal or no effect of breastfeeding on weight.  I'm not sure if this was intended as an exhaustive review of the literature on this subject, but there are certainly studies which do show an effect which could have been presented. 

I was disappointed by several statements she made about breastfeeding duration.  One statement, "most doctors currently recommend that mothers not introduce solid foods to their babies for at least four months," should at least have been followed by the AAP recommendation that solid foods not be introduced until babies are six months old.  She also states that one way to view breastfeeding is that "the first nine months are for building the baby, the next nine are for breastfeeding her," though the AAP recommends breastfeeding "for at least the first year of life."  In another section, she states that having a cesarean section birth "will not impact the timing of you milk coming in," though numerous studies (one here) have demonstrated an association between c-sections and delayed onset of mature milk.

Behan warns mothers that lactic acid increases in breastmilk after a nursing mother exercises, which can cause babies to reject the milk.  A number of studies have found that this is only a concern if the mother engages in "exhaustive" exercise (and very few nursing mothers have the energy or motivation to exercise to that point), and sometimes even then there is no effect.  I'm always concerned when I hear this issue raised to nursing mothers, since exercise in the postpartum period is so beneficial for our physical and mental health, and so hard to find time to do.

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Breastfeeding and codeine.

Last year the FDA raised concerns about use of codeine in nursing mothers, after a two week old infant died of a morphine overdose resulting from maternal intake of codeine (in less than the amount typically prescribed). 

This issue has been in the news again this week after the release of a Canadian study documenting the same hazard.

Codeine is commonly prescribed for postpartum pain, and can be found in Tylenol 3.  When codeine is ingested an enzyme in our bodies metabolizes it into morphine.  Some mothers are "ultra-rapid metabolizers" of codeine, which means that the enzyme in their system more efficiently process codeine into morphine.  For those mothers, the amount of morphine in their milk is many times higher than others, and the concentration can be fatal to breastfed babies.

Some of us are more likely to be ultra-rapid metabolizers of codeine.  Dr. Thomas Hale, of Texas Tech University, and author of the indispensable Medications and Mother's Milk explains on his forum that the incidence ranges from 1% in Caucasians, to 10% in Greeks and Portuguese, to 29% in Ethiopians.  He also notes that at least 7-10% of Caucasians lack the metabolizing enzyme altogether, and cannot metabolize codeine to morphine, and so codeine is ineffective for these individuals.

So, what else could be used for postpartum pain?  Dr. Hale lists alternatives and guidelines for the use of strong pain killers on his forum.  You can also watch a brief FDA video on this topic.

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Let's talk about the expression "giving up."

Earlier this week I was reading this post about new data showing that 36% of mothers breastfeed until 6 months, and saw a comment by a mother who was offended by the expression "giving up," when used to describe the point when mothers stop breastfeeding.

I've never been comfortable using that expression.  I've seen so many mothers struggle valiantly to try to breastfeed that I just can't see stopping as an act of surrender or failure, which is what I think the term implies.  Whenever I hear a mother describe weaning as "giving up," and I feel a strong urge to point out her successes. 

I even tied myself in knots the other day when I jokingly said, in response to a mother who asked me how long after you wean a young baby your breasts continue to produce milk, "Your breasts don't give up that easy."  I then got really flustered and later in the conversation apologized for implying that anyone was giving up anything.  They looked at me like I'd sniffed too many baby wipes.

What do you think ?  Is this an expression we should give up?

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Pumping through chemotherapy: Jenn Michelle's story.

Today I'm honored to have Jenn Michelle guest posting on the blog.  Jenn Michelle was diagnosed in May with Hodgkin's lymphoma.  She had to wean her daughter in order to start chemotherapy, and is pumping in hopes that she will be able to resume nursing once the treatment is done.

The pictures in this post show Jenn Michelle with her daughter, Jenn Michelle and her daughter at their last nursing session, and "nursing" now.  In another post, Jenn Michelle says that her daughter now kisses and hugs her breasts and her scars all day long: "She's trying to make her mommy all better with her kisses, because she knows that's when she can have her nursies back."

6/13 Yesterday afternoon, shortly before 12:30 pm, I nursed my sweet baby girl for what I can only pray was not the last time.  I sobbed silently, my tears dripping onto her curls while a swarm of my closest friends and family buzzed around the kitchen.  I was losing my religion in the living room and the day was only halfway over.

6/14 The first night after my treatment was awful.  Nugget sobbed hysterically in my arms, giving way to heavy sighs between her defeated attempts for true comfort, until she finally fell asleep.  I cried, and cried, and cried.  And between the tears I apologized over and over to my sweet baby girl for being sick.

6/24  I was so angry the first few times I pumped after staring chemo.  It was like rubbing salt in the wounds.  I couldn't nurse Nugget and I had to stand uncomfortably in the bathroom watching my milk fill up plastic bottles instead of a happy baby.  And then as I would dump the ounces of heartache down the sink a new wound would appear like a gaping mouth to catch my salty tears and sting my aching soul.

You won't find much if you Google "cancer" and "breastfeeding" except for articles about nursing after breast cancer.  "Chemo" and "breastfeeding yields the same contraindication tagline over and over, and "cancer" and "breastmilk" mostly just points you to article after article about this guy who drank breastmilk to fight his prostate cancer.  Those, mostly sensational and local news articles mention milk banks selling milk to cancer patients when they have an excess available to sell.  It costs $3 an ounce.

I've had plenty of time to think about that guy and those $3 ounces while making up songs to the pump's rhythm and calculating how much I'd just poured down the drain. Warning!  Here comes the crunchy freaky part.   Why the !?@* would I want to keep dumping my milk down the drain when other cancer patients are paying good money to get their hands on it?  I don't know what exactly it might do for me, but it sure won't be doing anything at the bottom of the sink, that's for sure.  So I sucked it up and sucked it down.

It was sort of gross at first, though exactly why I'm not sure.  I think it was the temperature.  I can't think of any beverage I regularly consume at body temperature.  But now I'm used to it and pleased by the thought that I might actually be doing something to help save my own life.

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A great video on latch.

Last year Ameda released a great video on getting a comfortable and effective latch.  Since this is really the heart of getting breastfeeding off to a good start, I thought it would be good to spread the word about it. 

The thing I like most about the video is that they show a mother starting with her baby skin to skin on her chest in a way that really lets you see the head-bopping...lunge instinct babies have.  The more I suggest that mothers try this, the more sold I am on starting in this position.  It's made a big difference in some cases, especially for babies who are refusing the breast.  Have you seen your baby do it?

The video also emphasizes the "asymmetrical latch" (without calling it that) which helps get the nipple into a comfortable spot.  Learning to help a baby latch this way has made a big difference for many moms I know, too.

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Can you be a feminist and breastfeed?

This Monday morning I want to talk about something complicated but really interesting.

I was recently reading an article on breastfeeding and feminism called "Is Breastfeeding Fair?" by Dr. Deborah McCarter-Spaulding, IBCLC. 

The article outlines "the feminist problem of breastfeeding."  What's that, you ask?  McCarter-Spaulding provides a summary:

"The problem arises because breastfeeding is sex-specific, and therefore challenges the feminist principle of gender-neutral childrearing.  It is an even more difficult problem than pregnancy because whereas pregnancy is necessary for childbearing, many do not consider breastfeeding to be critical to an infant's survival, at least in industrialized countries."

So, to summarize, feminist theory views social expectation and roles as potentially oppressive to women.  Pregnancy is a part of parenting that obviously cannot be shared, but some argue that breastfeeding doesn't fall in the same category.  Some feminists (see below) view infant feeding as an activity that can and should be shared equally.  You can only get to this point of view, it seems to me, if you think that breastfeeding is not a biological imperative.  And that is the argument that some feminists (not all, see below) make, questioning whether there truly are health benefits to breastfeeding. 

There are, however, several different feminist views on breastfeeding.  I'll summarize them here:

Liberal feminism:  In this view, breastfeeding is a social arrangement.  Lactation - making milk - is a distinctly female biological function which only women can perform, but feeding the baby is a form of social labor which can be negotiated.  Proponents of this view question claims of superiority of breastmilk over formula.  McCarter -Spaulding says that in this view, "Breastfeeding is seen as a gender difference that stands in the way of liberating women.  Bottle-feeding in this perspective would be seen as liberating."

Cultural feminism:  In this view, breastfeeding is seen as a special female role which should be protected.  In this view, complete gender equality may threaten those things that are uniquely female and male.  McCarter-Spaulding states, "Cultural feminism strives to reconfigure social and economic structures to accommodate this gender difference without resorting to biological determinism."

Feminist health activism:  In this view, breastfeeding is part of a political agenda which is aimed at helping women take control back over their bodies with information and support (think Our Bodies, Ourselves, but also La Leche League).  Viewed as a unifying perspective, this approach focuses on removing barriers which constrain women's choices, such as lack of paid maternity leave, the absence of break time or facilities to pump at work, and the particular challenges faced by disadvantaged women. 

I'd love to hear your perspective.  Do you consider yourself a feminist and also a breastfeeding advocate?  Do you think that it's possible to come up with an arrangement which allows for equal division of responsibility while allowing a mother to breastfeed?  Which of the perspectives above, if any, appeals to you?

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When breastfeeding causes bad feelings: Dysphoric Milk Ejection Reflex.

Today I'm pleased to bring you an email interview with Alia Macrina Heise.  Alia is a mother of three who lives in the Finger Lakes region of New York.  She is a WIC breastfeeding counselor, a postpartum doula and a certified lactation counselor in private practice.

Alia has been working with a team of physicians and lactation consultants to identify a problem recently termed Dsyphoric Milk Ejection Reflex, or D-MER.  She runs the website, DMER.org.

What is D-MER?

The official definition of D-MER (Dysphoric Milk Ejection Reflex) is a newly recognized condition causing a brief surge of dysphoria, or negative emotions, that peak before the milk ejection reflex, or letdown, in a lactating woman and then dissipates quickly after the milk release.

But put more casually, what a mother with D-MER experiences is a wave of unpleasurable emotion that hits when she begins to breastfeed and then fades a few minutes later. The feeling varies for each D-MER mother to some degree but can include a sinking feeling in her stomach, a feeling of hollowness, anxiety, panic, sadness, restlessness and self disgust. This wave of feelings corresponds with her release of milk, but many mothers don’t make that connection.  There are three reasons for this: Firstly, because the mother also has the feelings with spontaneous releases when she is not breastfeeding; secondly, because not all mothers feel a letdown tingle in their breasts to connect the emotion with letdown and thirdly, because the emotional overload happens just prior to milk release, making it something that is not always easily connected for some mothers.

  

What was your experience with D-MER?

I began experiencing what is now known as D-MER when my third baby was born almost a year ago.  I did not experience the same reaction to letdown with my first two babies. As a lactation counselor it seemed to me that there ought to be information somewhere on such a phenomenon, but I could not find any. I did find however, within about one month’s time, about 100 other mothers who experienced the same thing and they had all thought they were alone in their experience. So I sought out the more qualified lactation professionals to help me investigate D-MER and since then D-MER has gained a large amount of attention and is continuing to gain recognition.

 

How common is D-MER?

It seems that it is more common than anyone would have guessed. We are finding is that this is one of breastfeeding’s best kept secrets. Women have been embarrassed, fearful and self conscious about bringing up the negative emotions they feel while breastfeeding, even to their best friend or mother. This is because there is a strong message that breastfeeding feels 100% pleasurable, even warm and fuzzy, and so a mother who experiences the exact opposite, things like guilt, anger, irritation, hopelessness and dread, feels very much like a “freak” and a “weirdo.”

What is known about the causes of D-MER?

We have come very far in a short amount of time, but we surely haven’t come far enough in terms of knowing what the exact mechanism of D-MER is. We probably know 1000 things or more that aren’t the cause of D-MER and that brings us that much closer to finding out what is.  Oxytocin is involved, but not as the culprit, more as the messenger.  We can know this because mothers experience D-MER before a letdown, probably about the same time oxytocin is being released in the brain. The rest of the puzzle will be figuring out the other parts of the hormonal milieu involved. Prolactin, dopamine, the pituitary, the amygdala and others are all being investigated.

Does D-MER go away?

It can self-correct, but that varies from mother to mother. For mothers with mild D-MER it is likely to self-correct around the third month. For severe D-MER it often won’t self correct until well after the first year, or sometimes not until weaning.

Where can mothers get more information about D-MER?
D-MER.org is the largest source for D-MER support at this time, as D-MER is still gaining recognition.  Not only does it contain comprehensive information about D-MER, but it has quotes from other mothers, informational handouts available for download, a forum dedicated to D-MER, a survey for mothers who have experienced D-MER to take to help with the investigation of D-MER, and a lot more.

The 17th Carnival of Breastfeeding: Taking a bottle.

Welcome to this month's Carnival of Breastfeeding!  June's theme is pumping, and since all that pumped milk has to go somewhere, I thought I'd write about breastfed babies and bottles.  Be sure to check out the great posts from other bloggers on the topic of pumping at the bottom of this post.

Whether you're introducing a bottle because you're going back to work, or you want to share some feedings with your partner, there are some tips below that can help.  I've also included some strategies for dealing with a baby who won't take a bottle.

Speaking of which, here's a great example of a baby who isn't at all interested in bottles.  Thanks to Alicia for posting it!

Tips for introducing a bottle:

• Wait until roughly the end of the first month to try a bottle.  Before that time, some (not all) babies develop a nipple or flow preference and may have a hard time latching on to the breast correctly, or even refuse it.  The danger of this is greatest in the days and weeks right after birth.

• Don't wait too long, since at some point babies will reject the bottle.  In my experience this happens most often with babies who haven't tried one by six weeks.

• If it's important that your baby be able to take a bottle (for example, you'll be returning to work), after introducing the bottle at four weeks, continue to re-introduce the bottle at least a few times a week.  Don't go overboard with it, though.  Up to a bottle a day is usually fine, but too many may cause latch difficulties or breast refusal.

• Have someone other than yourself introduce the bottle.  Babies are smart, and some won't take one from you because they know you have the goods.  Some books recommend that you stay out of the room when a bottle is given.

• Practice "paced feeding (halfway down page)," which helps the baby manage the flow of milk.

• Use a bottle nipple which is more like a breast (with a wide base), and use the slowest flow nipple at first.  You'll probably also want to look for bottles that are BPA-free.

• If you're going back to work, gradually increase the frequency of bottle feedings so that your baby is solidly taking the bottle by the time you return to work.

Tips for babies who refuse bottles:

• Don't force it.  This doesn't work, and often makes the situation worse.  If your baby refuses, like the one in the video above, take a break and try again at a better time (see below).

• Experiment with different nipples, different size nipple openings (for flow).  Try to match the nipple shape and flow with your own.

• Use distractions like movement, talking and singing, going outside.  The Nursing Mother's Companion has a good picture of an outward-facing hold which seems to work for some babies.

• Try at times when the baby is sleepy, in a good mood, or not hungry.  In general, the more hungry and distressed a baby is, the more "disorganized" he/she is likely to be.  In that state a baby is less likely to do something new or difficult.

• Make sure that your milk doesn't taste or smell "soapy."  This may mean that you have excess lipase in your milk. 

• In a pinch, try other feeding devices, like a medicine cup, finger feeder, syringe feeder, or sippy cup.

• Know that your baby will be fine even if she/he only "sips" while you're gone.  He/she will make up for it when the two of you are together, a pattern known as reverse cycling.

• Say to yourself, "this too shall pass."

Be sure to check out these great posts from our blogging friends (updated throughout the day):

• Raising Baby Bee writes about pumping at work (and shares a great 'do not disturb' sign).
• Breastfeeding Mums says "electrify me!"
• Breastfeeding 1-2-3 writes about exclusively pumping for a baby with a cleft palate.
• Hobo Mama writes about donating milk for an adopted baby.
• Adventures of a Breastfeeding Mother shares her pumping tips.
• The Attached Mother writes about pumping and becoming a milk donor.
• Mama Knows Breast invites you to enter to win a free Medela Freestyle pump.
• Mike and Toni's writes about how a pumping experience turned into a business idea.

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"Aren't you just doing that for yourself?"

You may have heard this idea before - a mother breastfeeding because she wants to, not because the baby wants to, or for any benefit to the child.

A variation goes something like this:  "After a baby is (six months, one year, 18 months) it's just about what the mother wants, not what's good for the baby."  Sometimes we even say it to ourselves: "I just can't bring myself to wean her.  I guess I'm being selfish because I can't let go."

I've been thinking about this idea a lot recently, prompted by some of the discussion on weaning spurred by this post on weaning. 

I've been thinking about where this idea comes from.  Here are my ideas:

1) The misconception that a mother can choose to breastfeed a child who doesn't want to.  I can say from experience that if a baby doesn't want to nurse, you simply cannot force it to.  Any of you who have had babies with "breast refusal" will know exactly what I mean. 

2) The misconception that formula is as good as breastmilk.  Of course you know that this isn't true, but as a result of some effective marketing, the percentage of mothers who say that it is has increased by 50% between 1999 and 2003.  So, if there's no real difference between the two, the mother must be breastfeeding for herself.  Diana West did a good job of pointing this out in a podcast interview I did with her.

3)  The misconception that, at a certain point - one year, or 18 months - breastmilk declines in quality. This assumption, which mothers sometimes hear even from doctors, can easily lead you to the conclusion that a mother who nurses beyond that point is doing it for herself.  The facts are that breastmilk continues to provide important nutrition and immunological protection, and that some immunologically important components of breastmilk actually increase as the amount of breastmilk the child gets decreases.  Nature is no dummy.

4)  The view that a mother could be breastfeeding solely for her own health.  Until a reader left a comment reflecting that idea, it had never occurred to me that the research showing benefits like a reduced rate of cancer and faster weight loss could be turned around to blame women for wanting to nurse.  As for the concept of a mother making a child nurse, see #1.

5)  Discomfort with "extended" breastfeeding.  Extended breastfeeding, which is really the historically normal course of breastfeeding, is so uncommon in this country that the idea of a nursing two year old just doesn't compute.  It can only be explained by the mother's desires.

Mothers nurse their babies for all kinds of reasons - for good health, for financial reasons, for environmental reasons, among them.  And yes, being successful at breastfeeding, however one defines it, can make a mother feel good about herself.  But to accuse mothers of breastfeeding solely "for themselves," especially when so many mothers struggle valiantly to do it, and if anything put aside their own needs to be able to breastfeed, is just misguided and even cruel, in my view.  I'd love to hear what you think.

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Preparing to breastfeed, when your sister is carrying your baby.

I feel so lucky to be able to present this guest post by Karma, author of the blog "She's Having our Baby."  Karma, who lives in Toronto, has been inducing lactation so that she can nurse her baby, who is being carried by her sister. 

My journey to becoming a mother will have taken approximately 1,825 days by the time our daughter arrives this June.

My husband and I are nearing the end of our third trimester, but if you saw us we would look no different than before we were expecting. That’s because it’s my younger sister who is now sporting the baby bump, our baby bump. She’s our gestational carrier - meaning the baby she's growing for us is biologically our child, but is in her uterus.

So back to the beginning, and I promise I'll be brief:

Diagnosed with Non-Hodgkin’s lymphoma at 30; had just met my now husband, then boyfriend only a month before so things were BRAND new; cancer treatment meant I'd lose my fertility so we had to decide in 24 hours what to do - did I mention we'd only be dating for a month? 

So we decided to move forward with an IVF cycle, which resulted in 20 embryos. Fast-forward a couple of years: now married, we decide to thaw some of our embryos out to see what could happen and we embark on what I honestly thought would be our baby-walk-in-the-park. Not even close...endless hormone cycles, transfers, tears, frustrations, and no success. We finally admitted defeat. Enter my sister - our savior and currently 38.5 weeks pregnant with our little girl. 

One of the things I’ve been very excited about is the prospect of breastfeeding our little girl. I had no idea this was even a possibility until our fertility doctor casually asked if I was planning on doing it. I was immediately like, “Yes! If I can…how can I?” That’s when I first heard about Dr. Jack Newman and learned that there are ways to induce lactation. 

I was on the accelerated protocol, which consisted of the birth control pill for about eight weeks, while also taking a drug called domperidone, normally used for digestion. Almost instantly I was STARVING – that’s just one of the side effects of domperidone, along with inducing lactation. Then after the eight weeks, I stopped the birth control pill and started pumping.

It’s been over six weeks of pumping six times during the day and once in the middle of the night. I’m using a double electric pump, which seems to be doing the trick. I got drops on my first pump session, and have now progressed to about 8-10oz per day, depending on the day. I’ve found Gatorade and daily oatmeal have made the biggest impact on my production, along with the 120mg of domperidone every day. The pumping hasn’t been easy – I work full time and trying to find time during the day to pump, amid meetings, has been a challenge. I’m tired from getting up each night to pump, but also know this will be good practice for the newborn phase. 

But whenever I’m feeling frustrated by the pumping, or by the production, I remember why I’m doing this. Number one, it’s the best thing for our little girl. Number two, breastfeeding is going to be the most “normal” part of having this baby so far, and I can’t wait to be like every other new mom.

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