Why Weigh and Feed?

The most common task done during a lactation consult is weighing the baby. Often the baby is weighed before and after feeding. This practice is called many things: pre and post feed weights, PC/AC weights ( pre-consumption, after consumption), or weighted feeding. The purpose of this weighing is to determine how much milk the baby is transferring for that feed.

Human milk has roughly the same weight per volume as water: 1 gram per milliliter. We use this 1:1 ratio to get a pretty good idea of how well the baby is drinking at the breast. A baby who gains about 2oz after a feed too in about 2oz of milk from the breast.

The sensitivity of the scale used if a factor in determining the accuracy of the weighted feed. In this episode, Danielle meets up with Katherine Morrison IBCLC, CLC of Atlanta Lactation and Christie Coursey IBCLC of Breastfeed Atlanta to discuss scales, weighs, and how to decide on volumes to supplement based on weighted feeds.

Key takeaways from the video:

  • every baby should be fed to satiety at every feed
  • scales can give good data that needs to be examined along side data like diaper count and growth patterns
  • stool frequency and volume are important indicators of intake when scales are not available

Enjoy the video! Subscribe to our YouTube channel and comment to let us know what videos you’d like to see!

 

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Laid-back Breastfeeding

Laid-back breastfeeding, also called Biological Nurturing, is a method of baby led breastfeeding that starts with the mother first being in a comfortable reclined position. The keys to this position are:

-tummy to tummy on top of mummy

-baby is given time to seek the breast

-baby is free to explore the mother’s body with hands and head

-the nipple is still (mom is not holding the breast as a bottle)

Here’s a video of how this position is achieved on our YouTube channel: https://www.youtube.com/watch?v=PKoEnqrSkvs

Laid-back nursing is ideal for babies who have latch on difficulties from a high palate,  bubble palate, tongue tie, lip tie, recessed chin, or birth trauma. Most healthy full term babies can achieve this position from birth.

Laid-back breastfeeding increases skin-to-skin which helps babies coordinate better for feeding and improves mom’s milk production. This position also adds gentle pressure to the abdomen to help babies release gas more easily.

Laid-back breastfeeding is the original tummy time, leading to the other label “biological nurturing.” Babies nursed frequently in this position may avoid flat spots on the head and enjoy on or above target physical development because they are engaging in developmental appropriate baby “exercise.”

Tummy down feeding stimulates baby’s inborn feeding reflexes. This position helps the jaw rock forward, the neck and head lift, and the arms work the full range of motion. You may find your baby making motions very similar to swimming in this position. These movements will later translate into skills for rolling, sitting up, pulling to standing, and crawling.

 

10 Questions with a Pediatric ENT

1) How can an ENT be part of a breastfed baby’s healthcare team?

Successful and efficient breastfeeding requires the tongue and lips to have adequate mobility (structure) to stably maintain an airtight seal between the tongue, lips, palate and nipple during the process of extracting milk, as well as proper strength, coordination, and movement (function) of these tissues. This is why optimal treatment of breastfeeding problems may require a team effort between the pediatric ENT to address the structural concerns, and a lactation consultant and/or occupational therapist to address the functional concerns.

2) Is tongue tie a fad diagnosis? Why has there been such an increase in tongue tie revision in the last decade?

Tongue ties have always been around, but the increase in emphasis on benefits of breastfeeding, and less willingness to accept the advice just to bottle feed if breastfeeding is difficult, have led to an increased exploration and awareness of tongue tie as a treatable structural concern that may improve the comfort and efficiency of feeding.

3) What is the reason for controversy about tongue tie? Why do so many healthcare providers disagree on this diagnosis?

There is a spectrum of ways in which the tongue can attach to the floor of mouth, and some tongue ties, particularly those that are anterior, are more obvious than others. The presence of a tongue tie that is less obvious is diagnosed by the feeding pattern more than the exam. Those who do not have a good understanding of the ways in which the relationship between the tongue, lip, jaw, palate and nipple can affect breast feeding, may not be willing or able to recognize a functionally significant tongue tie if it is not readily visible. The tongue-tie feeding pattern is a consequence of inability to maintain an airtight seal due to an imperfect relationship between these structures, which leads to a cascade of potential issues including shallow latch, frequent separation/repositioning, nipple pain/cracking/blistering, plugged ducts or mastitis, clicking/air swallowing which makes the baby gassy and fussy after feeds, biting or chomping behaviors (as the baby works as hard as they can to maintain the latch given the structural limitations), leading to fatiguing during feeds before obtaining adequate milk intake, resulting in frequent, inefficient cluster feeds. If these symptoms are present, it should prompt evaluation for an oral tie.

4) Do all tied babies need a frenotomy? Are there evidence-based non-surgical options to resolve this issue?

How likely the frenotomy is to be helpful for breastfeeding problems depends on how much tethering tissue can be released, relative to how restricted the movement is. If the baby has feeding issues suggestive of tongue/lip restriction, then a frenotomy is likely to be helpful. Beyond breastfeeding, the frenotomy is particularly recommended for babies with anterior tongue ties, which are more likely to affect speech articulation.

Non-surgical treatment cannot address the structural restriction of the tongue and lip. Although some babies may gain more strength and coordination, and be able to compensate better, the structural relationships do not change. Toddlers will often fall and lacerate the labial frenulum, but it’s not exactly a workable treatment plan.

5) What is the role of the palate in diagnosing tongue tie?

The tongue must have enough mobility to rise up and pin the nipple against the palate to maintain an airtight seal. If there is a high arch to the palate, then the tongue has to elevate further in order to achieve enough surface contact to achieve this seal. So it is often more the relationship between the tongue and palate, rather than the tongue itself in isolation, that determines whether the baby will have a tongue-tie feeding pattern.

6) Plenty of moms are posting photos on Internet forums asking if their babies have a tie. Can you make a diagnosis from a photo? Is there a difference between form and function when diagnosing ties?

Anterior tongue ties, where there is an obvious tethering band restricting movement of the tongue tip, can be diagnosed from a photo or examination alone, although the history is still helpful in determining how much it is affecting feeding. Less obvious tongue ties are diagnosed much more by the feeding pattern than the exam. There is not always a good correlation between form and function, because there are so many other factors beyond the visible structure of the tongue and lip which may affect the latch. My approach is that the feeding pattern (function) tells you that a tie is present, while the exam (structure) tells you how much of a target you have to improve the situation.

7) What are the long term consequences of untreated oral ties? Is there a way to predict if a tie will be problematic down the road?

Untreated oral ties can contribute to feeding problems with handling certain textures of solid foods, dental hygiene problems including cavities (imagine not being able to use your tongue tip to dislodge crumbs caught between the gum and cheek), and speech difficulties (try to talk while holding your tongue tip against the inner surface of your lower teeth, and you will hear the effects on articulation).

Again, since form and function do not always correlate, it is difficult to predict for sure how much these effects will occur if the tie is untreated. As a rule, the closer the tie is to the tip of the tongue, the more likely it is to affect speech. As the procedure is easier and better tolerated in younger infants, and it is better to prevent the speech problems than to treat later and need speech therapy to re-learn articulation, I am in favor of early treatment once a tie is identified.

8) Why do so many healthcare providers seem to miss this diagnosis? Many moms report being told the latch looks great even though they experience pain. What should they be looking for instead?

Again, this comes back to frequently poor correlation between the exam and the feeding pattern. Many providers are trained only to recognize the structurally obvious anterior ties, or may have even been taught that tongue ties do not affect breast feeding, because some babies with visible tongue ties are able to breast feed without difficulty. (This is like saying that smoking does not cause cancer, because some people smoke their entire lives and never get cancer). Recognition of the tongue tie feeding pattern (see #3) should help determine when a baby could benefit from tongue tie evaluation and/or treatment.

9) Other than oral ties, what other conditions do ENTs treat that may require special breastfeeding support?

Conditions that affect the tongue, jaw and palate, such as cleft lip and palate, Pierre Robin and other craniofacial syndromes, or tongue cysts, may make breast feeding difficult or impossible and require special support.
10) Laser vs scissor: any truth that one is better?

There are no head-to-head studies comparing them, although some providers are laser proponents because there may be less bleeding, which potentially allows the procedure to be done without a local anesthetic (numbing injection), or because it may allow for a more precise cut. On the other hand, laser is possibly more dangerous if the baby moves, certainly requires more setup time and precautions, and is a much more expensive piece of equipment. So I see no convincing evidence to prefer laser over scissors, especially for office-based procedures.
Bonus question 11! Share a memory or reason breastfeeding had a positive health impact for your family.

When my wife and I were in residency and she was on call, I would pick up my son from daycare and bring him to her to breastfeed, then pick up all the bottles she had pumped during the day so that I could feed him overnight. It was nice for them to have that bonding moment in the midst of her busy day, and put him in a better frame of mind to come home with me for the evening.

~~~~

From very early on, Dr. Erik Bauer has been fascinated with language and communication, which led him to an interest in hearing and speech, and from there to the versatile specialty of pediatric otolaryngology. Born and raised in Chicago, Dr. Erik Bauer graduated from Harvard University magna cum laude before enrolling at the University of Michigan Medical School. He went on to surgical internship and residency in Otolaryngology-Head and Neck Surgery at Washington University in St. Louis, Missouri, then stayed on for the Pediatric Otolaryngology fellowship at St. Louis Children’s Hospital. This fellowship prepared Dr. Bauer to recognize and treat a full range of pathologies including pediatric hearing loss, cochlear and BAHA implantation , chronic ear disease, congenital and acquired airway problems, foreign bodies, and sinus disease.

Dr. Bauer joined Pediatric Ear, Nose & Throat of Atlanta in September 2006. In practice, Dr. Bauer has developed a special interest in tongue and lip ties, especially as they affect infant breast feeding. He feels fortunate to have learned a lot about this previously under-recognized issue, and to have the opportunity to help many infants and moms navigate this challenging territory.  Allowing babies to feed more comfortably and effectively has turned out to be one of the most rewarding aspects of his practice.

Outside practice, Dr. Bauer does his best, along with his wife Mandy, a breast radiologist, to keep his two active boys entertained, between helping with science fair projects and social studies homework, shuttling to soccer and chess tournaments, and attempting to make sense of their video games. He also enjoys travel, dining, live music, and trying to teach himself languages with varying degrees of success.

Dr. Bauer is a diplomate of the American Board of Otolaryngology, having received his board certification in June 2006, and a fellow of the American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Pediatrics. He practices at our Main Office, Alpharetta, and Marietta locations.

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Breastfeeding is MORE than Milk

 Breastfeeding provides perfect nutrition for infants, but it also does much more! Direct nursing at the breast has a whole host of benefits that are easily overlooked in a culture so focused on the milk. Nutrition is only one aspect of infant feeding that leads to growth and development.

Muscle Mechanics:

  The muscle mechanics involved with nursing facilitate optimal cranial-facial development. You’ve probably heard about importance of “tummy time” for the development of head control. Nursing your baby in a laid back position is tummy time made easy! Breastfeeding also coordinated the right and left hemispheres of the brain because the baby is moved from left to right on the mother’s body. This brain development is critical to other developmental milestones like crawling, walking, and later reading. The developing infant palate, mouth, and skull are shaped by feeding. Feeding at the breast helps the baby achieve normal oral motor function and growth.

Skin to Skin:

    Breastfeeding inherently provides the skin to skin contact newborns need for early neurological development, body temperature regulation, and blood sugar regulation. The mother-baby bonding that occurs while a baby is at the breast is unparalleled. Studies show held babies have lower stress hormones.

Increased Maternal Rest:

    Exclusively breastfed infants who sleep in close proximity to their mother replicate their mother’s REM cycles.  Since their sleep is in sync, the baby is more likely to wake for nursing when the mother is not in a deep sleep state.  Maternal sleep is a crucial part of postpartum recovery. Studies show that breastfeeding moms actually sleep about 45 minutes more per night than formula feeding moms.

Better Maternal and Infant Mood:

    Breastfeeding facilitates the release of the “feel good” hormone oxytocin in the mother during “let down” or milk ejection reflex. Mothers of breastfed babies experience less postpartum depression.  Breastmilk contains multiple hormones that promote happiness and relaxation in infants. Breastfed babies also are less likely to have colic.

Infant Sleep/Wake Cycle Regulation:

    When babies are first born they do not make their own sleep hormones. The newborn receives the sleep hormone melatonin directly from breastmilk. The act of suckling at the breast releases a hormone in the baby called CCK, which makes him or her feel full and sleepy. Nursing to sleep is good for babies!

Protection from Sudden Infant Death Syndrome:

    Frequent night wakings to nurse are a large part of normal infant sleep, and serve as nature’s protection against SIDS. Bottle feeding human milk through the night has not shown to be as protective in preventing SIDS as direct nursing at the breast.

The American Association of Pediatrics recommends exclusive breastfeeding for the first six months of life, and continued breastfeeding with complementary solids until at least age 1. Continued support is a huge factor in long term EBF success. A prenatal visit with a lactation consultant or lactation counselor is the first step. An LC can answer your questions and assist you with formulating a breastfeeding friendly birth plan.  If you have already had your baby, schedule a home visit or clinic visit with your LC for an in depth consult that can help your family realize all the benefits of breastfeeding.

Bringing Your Newborn Home

Bringing your infant home can be both exciting and scary. You may wonder what your family’s new normal will look like. Many refer to this period of time as the “fourth trimester,” or the period of time when mom and baby both adjust to their new physically separate states. This adjustment takes place over the course of several months. When your baby is first born he or she has no experience with the world beyond the womb. Certain things can facilitate the ease of this transition from the womb to your arms. Bonding is the name of the game during the first days home. “Eat, bond, sleep, repeat” becomes the new mother’s mantra.

    The natural habitat of the human infant is mother’s breast. Your baby will likely spend most of his or her time there for the first few months. Since newborn nutrition is such a large part of life with a new baby, taking a prenatal breastfeeding class is essential. You may wish to speak to an LC one on one to discuss your questions or concerns specific to your family prior to your baby’s arrival.  A prenatal breastfeeding consult is a helpful tool for preparing you with information about establishing the nursing relationship. Most of the time in Atlanta area hospitals, you will have the opportunity to receive a quick consult from a hospital lactation consultant prior to your discharge. This consult is generally brief. Many families still have questions and concerns regarding breastfeeding after returning home. Many new moms prefer to schedule home visits with their LC to stay in the comfort of  home during the recovery period.

 Breastmilk is digested in 90 minutes. Expect to nurse your baby 10-15 times per 24 hours. Many first time mothers worry that their baby nursing frequently is a sign that they do not make enough milk. This is usually not the case. Colostrum, or newborn milk, is present in your breasts starting early in the third trimester. It is nutritionally rich and very little is required to fill a new baby’s tiny stomach. If your baby experiences the common condition “jaundice” also called hyperbilirubinemia, colostrum is a powerful laxative that will help resolve it. Within the first few days your milk will transition to “mature milk.” Each time your baby nurses, it signals your body to make more milk. Frequent on-cue nursing during the newborn period generally equates to a robust milk supply in the long term. Exclusive breastfeeding or “EBF” and avoiding formula are common goals for many mothers. This goal is attainable with access to breastfeeding education and breastfeeding help if necessary.

    The best indicator of adequate intake is output. Normal diaper count is 6-10 wet or dirty diapers daily. In the first week, counting diapers can give you reassurance that your baby is indeed eating enough. Your baby should have at least one stool per each day of life. Day one- 1 poop, Day two- 2 poops, Day three- three poops, and so on. “Cluster feeding” or blocks of frequent nursing are common. Although nursing is frequent, it should never feel painful. Your baby will likely love to be held on your chest close to your breasts even when he or she is not nursing.

    Skin to skin contact is crucial for your newborn.  Skin to skin regulates the infant’s body temperature and blood sugar. It also facilitates important early neurological development. The simple act of holding your baby skin to skin stimulates production of hormones in both the mother and baby that keep everyone feeling relaxed and calm.  Your partner can help you with this important bonding process by doing things like screening phone calls, entertaining visitors, bringing you food and drinks, changing diapers, and caring for older children. Your partner should encourage you to rest as much as possible while your baby sleeps.

Newborn sleep gets a lot of publicity. When babies are born, they do not make their own sleep hormones. They receive their sleep hormones from their mother via breastmilk and suckling. This is why many babies nurse to sleep. Nursing to sleep is biologically normal and natural. Many people refer to babies “having their days and nights confused.” This is not the case. Babies are not born with a light/dark cycle. One will eventually develop with time, but during the newborn period frequent night wakings are to be expected.  Frequent waking to nurse is part of nature’s protection against SIDS. The American Academy of Pediatrics recommends a form of co-sleeping that is referred to as “rooming in” for the first six months of life as a measure of SIDS risk reduction. Sleeping in close proximity to your baby also allows to have a heightened awareness of your baby’s hunger cues throughout the night.

Your new baby’s first days at home will likely seem like more of a whirlwind than pregnancy.  Prenatal breastfeeding education and accurate expectations of the newborn period can make this transition much more manageable for families. However, there will be times that you don’t know what to do. When in doubt just do less, nurse more, and call your LC!

How Do Moms Pump Enough to Return to Work?

Many moms want a safety net of pumped milk in the freezer for their return to work away from their babies. While it’s only necessary to have enough milk saved for the first two days back at work, many moms want to save several days or even weeks worth of feedings during their maternity leave.

Please read What to Expect When Pumping to trouble shoot and get the most out of your pumping experience. This article addresses how to juggle pumping during your maternity leave and during the working day.

When to start building a “stash”

Most women start with over production. The first 10 weeks of breastfeeding are the easiest for milk collection. This is also a critical time for conditioning the body to respond to a pump. Ideally, moms should nurse on cue and spend a great deal of time resting skin to skin with their babies for the first 2 weeks. Once baby has regained birth weight, around day 10-15, it’s time to try pumping.

Milk collection is easiest in the morning hours when the milk making hormones are highest. Beginning at this favorable time will help make pumping a more positive experience. After nursing the baby, pump either one or both sides for 20 minutes each. Even if the milk stops flowing, continue pumping for 20 minutes per side.

Weeks 2-4, pump one time per day in the morning after nursing. Expect to collect 1-2 ounces each day. Remember: 20 ounces is enough milk for about 16 hours of mother-baby separation.

If you wish to increase your daily milk collection, add a second daily pumping session weeks 4-6. Pumping only twice a day will help you collect several days worth of milk before returning to work.

If your baby cues to nurse after pumping, just nurse. The breasts are never truly empty until you wean. The more milk removed, the faster the glands work to produce more milk. No pump is as efficient as a baby who is properly latched. There is no need to feed the baby the pumped milk in place of nursing.

If your maternity leave is longer than 6 weeks, continuing pumping 1-2 times per day as is possible for the duration of your leave. This helps maintain a conditioned response for more efficient pumping in the future.

When to Pump at Work
No two work environments are the same. No two work days are the same. Not every work environment allows for predictable or scheduled pumping sessions. Things to consider:
– aim to pump every 1-3 hours. This is a range. Babies and breasts are flexible.
– don’t feel trapped on a schedule
– if you anticipate a long meeting or event you cannot break out of, consider pumping once an hour for 2-3 hours beforehand and/or afterward
– your body does not require you to pump on a set schedule just as your baby does not feed at set time
– a hands free pumping bra can help you pump during your drive to and from your work location
– hand expression may help moms who have a short break but can’t make it to the pumping room
– taking a lunch break to nurse your baby may be easier than pumping as frequently at work

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