We discuss breastfeeding, including logistics and troubleshooting. We are joined by Linda Catterton, IBCLC at the University of Texas Southwestern Clements University Hospital.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern newborn nursery.
Dr. Neeta Goli:
Welcome back to the podcast. In today's episode, we'll be talking about breastfeeding. We are joined today by Linda Catterton, who's a lactation consultant at Clements University Hospital. She's been a nurse since 1980 and has had lactation experience since the mid-1990s. We're very lucky to have her with us today. Linda, thanks for joining us.
Linda Catterton:
Thank you.
Dr. Neeta Goli:
From a personal standpoint, despite having been a board certified pediatrician, having gone through residency and with some time spent in a lactation clinic and residency, I feel like I didn't truly understand the ins and outs and the logistics of breastfeeding until I had a baby of my own and breastfed her. My hope is that our listeners can understand a little bit more about the practical day-to-day management of breastfeeding and helping breastfeeding moms by the end of this episode. From a medical standpoint, the AAP does recommend exclusive breastfeeding for the first six months of baby's life, which means that babies should get breast milk with no other complementary foods. Then breastfeeding until 12 months with the addition of complementary foods when babies are six months old. Just to start off with, can you give us some more information about why we recommend breastfeeding, why it's so important for babies and their moms?
Linda Catterton:
Breastfeeding has many benefits, not only to the baby, but also to the mother. Breast milk is the perfect nutrition for babies. It has the components that they need for growth and development. It starts out with the colostrum, the perfect milk for babies. It's a small amount, but the immunizations that are present in the colostrum benefits of baby's health for life. Whether a mother breastfeeds for a day, a week, a month, a year, all of that has benefits to the baby. It protects against viruses and bacterial infections. It also protects the mother even against breast cancer, uterine, cervical cancer. There are just great benefits on both sides.
Dr. Neeta Goli:
When does a mom's body start making breast milk?
Linda Catterton:
It's at 16 weeks of the gestational age that the colostrum is starting to be developed. Then once the delivery occurs, the prolactin level, which is the milk making hormone, goes to a peak. It stays at a peak for about two to three weeks. For the first few days, the colostrum is there. That's actually called lactogenesis I from that 16 week gestation until the first three to five days when the milk begins to increase at lactogenesis II. Early on it's the frequent early stimulation that impacts the milk supply. Every time there's stimulation, it's hitting that receptor site for the prolactin to be released so that the body is having that order placed to make the milk.
Dr. Neeta Goli:
When you walk into a room to meet a mom, what are some things that you tell these moms?
Linda Catterton:
One of the things I'll ask them is, do you remember at the very beginning of the pregnancy, was there tenderness in the breast? Most of the time, and for the majority of women, they have tenderness at the very beginning of the pregnancy. When there's tenderness there, then there's the presence of the hormones that are developing the glandular tissue. Then when the baby is born, that's when the prolactin increases. When babies are first born, they should be placed skin-to-skin with the mother. That really is the best early intervention that we can do because when babies are born, they are ready to feed. They're awake, alert. They are looking to feed. Babies are born with a high suck need. When babies feed, they're placing that order for the milk that's going to come. When their skin-to-skin and feed soon after delivery, usually within that first hour, and then that first day, they may go through periods where they're very sleepy.
Linda Catterton:
That's when we bring in the hand expression. Hand expression is a very key component in increasing the milk supply and then giving the baby the drops of colostrum. Oftentimes, we'll spoon feed or even use a finger. Sometimes there's a few drops. Sometimes there's significant drops that do go into a spoon where we can spoon feed the baby. The second 24 hours, we expect babies to wake more, to feed more, to make more milk come. In that second 24 hours, when babies start to cluster feed, mothers may think, "Oh, I don't have enough milk because they want to feed all the time." That's actually how babies are making more milk come, with more frequent feeds. That second night, babies are usually awake and ready to feed all night long. They may sleep all day, but they want to feed all night. Really we have to prepare mothers for what's coming so that they know babies will be awake.
Linda Catterton:
They will want to feed and feed and feed. Even when we're asked, "How long can babies feed for a breastfeeding session?" Well, we really don't limit when they feed or how long they feed. If babies are showing the cues to feed, we start them on one breast, let them feed until they take themselves off. Then when they take themselves off, if they're still showing signs of hunger by looking to suck, looking to bring their hands to their mouth, then that's when we'll put them on the other side. When we say feed on demand, it's allowing the baby to feed as often as they want, as long as they like. That's what gets that milk supply established.
Dr. Neeta Goli:
I know you mentioned the first day, sleepy baby, second day, hungry baby. For our listeners, I think this is one of the most important things that we can do to support breastfeeding moms is to let them know in advance that we can expect that the baby might want to feed all night and that's normal. That it's not necessarily a sign that mom isn't making enough milk. Now, what are things that you might be looking at to see if mom truly might not be making enough milk for baby?
Linda Catterton:
Well, early on, because there is such a small amount of colostrum, if we see at least one wet, one dirty diaper in the first 24 hours, then the babies are getting what they need. The second 24 hours, we're looking at two wet to dirty diapers. Now, if there is a significant weight loss after that first 24 hours, then that would be something that may indicate that the babies aren't getting enough. There may be risk factors on the maternal side, where she had a very difficult delivery or an unexpected C-section or the baby was separated from her for several hours. Those can be things that interfere with just the normal progress of the milk increasing ideally, as it should.
Dr. Neeta Goli:
Okay. What tips do you have to make breastfeeding easier for moms?
Linda Catterton:
What we really communicate early on, is feed on demand, hand expression, and skin-to-skin. A lot of times when babies are skin-to-skin, that even provides an easier way for them to latch comfortably because latch is a very important piece to comfortable breastfeeding so that there isn't pain. They can use a cross cradle hold, a cradle hold, a laid back position. They can use a football hold, and sometimes mothers even like that football hold, because they can see the baby. It lets the baby tuck under the breast and allow for an easier latch that's more comfortable for the mother. If there's pain with the latch, then we can do a little position changing so that it stays comfortable for the mother, to prevent that pain.
Dr. Neeta Goli:
Okay. Then when a baby first starts to suck, when do you expect moms should actually start expressing milk?
Linda Catterton:
Well, when babies first start to suck, you may see more of our rapid suck in the beginning. You may not hear any swallows for several minutes, but sometimes even we'll use hand expression or breast massage before or during the feeding of a baby. Then when they start sucking a little bit more, we usually hear a swallow. They're not that frequent. They're very quiet. It's more of a sound. If you can hear that as we record this, but we do listen for swallows. The main thing we look at is are they having wet and dirty diapers? We don't see what goes in, but we see what comes out. That's why it's important to keep a track of those wet and dirty diapers early on. Then the weight. That is really one of the most significant things on how baby is transferring milk, making sure that they're getting that breast milk.
Dr. Neeta Goli:
If we have a mom who is receiving lactation support, she's doing all the right things, doing what she can, what are the most common reasons that you feel like moms run into trouble, or they have difficulty with breastfeeding?
Linda Catterton:
Well, I think early on, one of the things is the latch. Sometimes they have difficulty in getting the baby to latch, and that can be a problem. Sometimes if they do latch, it can be a painful latch. That can be a problem for the moms. Of course, that impacts the milk. Now, if that occurs and too much weight loss has occurred, or we're not seeing the wet and dirty diapers, then the pediatrician may order supplementation. If supplementation is ordered, then usually we will start mothers pumping so that they continue to have that stimulation. Hand expression is another thing. Even to use hand expression with pumping will have an impact on the milk supply. Here we're trying to maximize the milk a mother can make. We don't know for sure what that's going to be and for many mothers, there are risk factors that they have where they may not be able to make the amount of milk needed for exclusive breastfeeding, but to use interventions early on so that that milk supply can be maximized with the prolactin level at a peak for those first couple of weeks. You can't wait until later to start all of these interventions to maximize the milk supply. Sometimes pumping just to establish milk supply, if the baby's having trouble feeding at the breast, because it has to be made sure that babies get what they need nutritionally.
Dr. Neeta Goli:
You mentioned that some moms might have some risk factors for not making enough milk. What kind of risk factors do you consider?
Linda Catterton:
Well, there are several that we see in the literature. Oftentimes, it can be even as slight as unexpected outcomes that cause stress and that stress can delay the milk from increasing. Sometimes it's impacted by the hormones, by PCOS. Oftentimes by maternal age. They even look at obesity as a risk factor for delayed lactogenesis. Diabetes. We have a lot of diabetic moms that deliver. Oftentimes, there are glucose issues with the baby. Oftentimes, when we have to use supplementation and using supplementation may delay the milk from increasing.
Dr. Neeta Goli:
Maternal thyroid disorders as well.
Linda Catterton:
Exactly.
Dr. Neeta Goli:
Yeah. In terms of the most common difficulties moms run into, you mentioned the latch, and then what are other questions and concerns that you often have to address from moms?
Linda Catterton:
Well, I think they desire to be, or most of the mothers, desire to be independent with breastfeeding early on. A lot of times they'll say that they can't do it by themselves if they need help. And sometimes it's hard for someone to always be there. So really to promote independence, give the mother confidence. Pediatricians are great. Even when they come to see mothers at promoting that confidence in mothers, praising them for choosing to breastfeed.
Dr. Neeta Goli:
Often when I have breastfeeding moms, I'll just say thank you for all the work that they're putting in. Sometimes on TV, in the movies, you see breastfeeding and it's portrayed as this beautiful, natural, magical experience, which it is once it's established, but in the beginning especially, it can be rough and it can be time consuming and difficult. We always like to make sure moms are acknowledged and all the work that they're doing is acknowledged and appreciated.
Linda Catterton:
Absolutely.
Dr. Neeta Goli:
What about pain? If moms say they have pain when baby breastfeeds?
Linda Catterton:
In fact, one of the questions I'll even ask a mother is how does it feel when your baby feeds? If pain is on that list, that means the baby is not latching correctly. Now, sometimes there may be reasons such as a tight frenulum, why a baby doesn't latch, where it's comfortable for the mother. That's something the pediatrician would look at, but if it is pinching every time the baby is latched, sometimes we can do a slight change in that position where the hips are more tucked in, the head is slightly more lifted. That lower lip is more flanged out so that pain doesn't occur. They'll feel a tug, but they shouldn't feel a pinch. If they feel a pinch, then that will cause damage to the nipples. That creates a whole array of problems for the mothers.
Dr. Neeta Goli:
If we do have moms who are having difficulty with breastfeeding, what kind of resources do we have to offer them?
Linda Catterton:
We have lactation consultants available in the hospital. There are outpatient lactation services. There are private lactation consultants that even come to the home. Oftentimes, pediatricians are a great source of help for the mothers. Sometimes there are even lactation consultants present in the pediatrician's office. That's always a great resource. I wish we had more of that in the community, because then with that early follow-up, they get more immediate attention. When they see the pediatrician. There are also WIC offices that offer lactation support. Then there's a lactation care center that's located at Medical District Drive and Stemmons Freeway. That is such an excellent resource for mothers at no charge.
Dr. Neeta Goli:
It sounds like we have lots of support available, locally at least, for our moms who are breastfeeding. Hopefully our listeners are aware and can refer our moms to those resources as needed. One question that I get every so often is if mom's taking a medication, she asks. If she can still breastfeed?
Linda Catterton:
We do get a lot of calls like that. Now, us as lactation nurses, we can't give that information to mothers, but we can provide information about the medication and then have them check with their physician about it. We have an excellent resource, Medication in Mother's Milk. It's a book that Dr. Thomas Hale has put together where he's actually looked at mothers who are on certain medications, lots of different medications. They look at how much is transferred into the milk and the effect that it has on the baby. Is it bioavailable for the baby?
Dr. Neeta Goli:
For our listeners, online, there is a website called LactMed. You can just do an online search for LactMed and it's the first link. It's a website put together by the NIH that has a lot of the same information. It's a great resource before telling mom that she's not able to breastfeed. We always want to make sure. I think sometimes if you haven't had a child or haven't breastfed, it's kind of hard to understand how much work goes into it and how precious that breast milk is, especially in the first couple of days. We want to make sure we're providing our moms with the most accurate medical information. Always make sure you look up your resources before you tell a mom to not breastfeed or to pump and dump.
Linda Catterton:
Absolutely. It really is a fragile time for mothers.
Dr. Neeta Goli:
Yeah.
Linda Catterton:
They're exhausted and doing the best they can.
Dr. Neeta Goli:
Yeah. It's tough. We're lucky to have support like you.
Linda Catterton:
Thank you.
Dr. Neeta Goli:
Linda, thank you so much for joining us today. This has been a really great talk, very educational. To end the episode, do you have any tips for success for our listeners as they take care of newborns?
Linda Catterton:
There is an excellent website. It's called firstdroplets.com. It is a 15 minute video clip that talks about this early frequent intervention. It also talks about the latch, getting that latch correct by guiding with the nipple up toward the palate of the baby's mouth, babies respond instinctively what they feel in their mouth. It really is an excellent resource that I think would help every mother, even every provider to view that that talks and gives great information about breast milk and latching.
Dr. Neeta Goli:
Thanks so much for sharing. We'll have to check it out.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.