I haven't posted in a while. But that's doesn't mean that I haven't been engaged with the world of breastfeeding. You could say that I've been doing field research. I've been breastfeeding my son. Until now.

It happened. He weaned. 

Parents often talk about how every pregnancy is different, every baby is different, and every kid is different. I laugh when I hear that. Not because it's untrue. It's true. For some families. My kids? They happen to be very alike. So it was no surprise that my son weaned at 14 months just like my daughter. It was like clockwork.

Weaning, by this definition at least, is the process of stopping breastfeeding. Weaning happens in different ways and for different reasons. Circumstances and timing cannot be universalized. So if a mom asks, "when should I wean?" A good answer is not an answer, but a follow up question, "when do you and your baby want to wean?"

According to guidelines a year of age is the standard. But that guideline is less of a standard than, well, a guideline. Confused? That's ok. It is confusing. And vague. On purpose. Experts generally agree that babies should exclusively breastfeed for 6 months and then continue to breastfeed until a year of age or longer. 

Can you wean before your baby is a year old? Yes. If your circumstances necessitate it, then you can. Most of the time mothers do this for (often complex) medical reasons, though some do so for personal reasons. Should you try to continue nursing until your baby is a year old. Yes. Will the universe collapse upon itself if you wean a bit sooner? No. If you wean sooner than a year be sure to talk to your baby's doctor about how to safely feed you baby using formula, table food, or both. 

Do you have to wean when you baby is a year old? No. There is no hard and fast rule on this one. Nursing doesn't have a deadline or an expiration date. Does that make you nervous? If so, then you're probably reacting to a culture that doesn't know much about toddler breastfeeding. And we often fear what we don't understand. 

Want to hear more about weaning? Stay tuned for Weaning, Part 2.

Registry Checklist for the Breastfeeding Mom-to-be

If you're an expectant parent you probably have one or more registries for baby gifts. In an effort to help you (and encourage you to spend more of your friends' and family members' money), many stores have a long list of registry suggestions or must-haves. But what do you really need?

Let's take a look at some of the most common items that you'll find on these lists. I'll give you my feedback about what I think you need, what I think you don't need, and what I think that you may want*.  I'll also tell you why. 

Bold means that you need it

Italic means that you don't need it

(Parentheses) means that you may want it



(Breast Pump) - If you are a breastfeeding mother who works outside the home you will need a double electric breastpump, unless you rent a hospital grade pump. If you are a stay-at-home mom or work-at-home mom, you may prefer a single electric pump or manual pump, depending on how often you plan to pump milk. If you're a stay-at-home mom who doesn't plan to bottle feed ever, then you may opt to skip the pump altogether. Don't forget to check with your insurance about a free pump before you put it on your registry.

Nursing Pads - You will likely need these for leaking at some point while nursing. You may need the leak protection throughout your time nursing. Keep in mind that these also protect your bra and tops from getting stained by your nipple cream. Should you go with disposable or cloth? That's up to you. I personally like the cloth. You may prefer disposable. Register for one pair of cloth and one box of disposable if you aren't sure.

(Breastmilk Storage Bags) - If you plan to keep a freezer stash then consider stocking up on some bags. Not sure if you'll store much milk? You can always buy these later.

(Nursing Cover) - If you plan to nurse in public with a cover or if you plan to pump in the car then register for a cover. If you plan to nurse in public without a cover or don't plan to nurse in public at all then you can skip it. Keep in mind that if you're so inclined it's fairly easy to make your own.

Nursing Pillow - Could you just nurse your baby on a regular pillow? Sure. Is it a lot easier to have a nursing pillow? Yes. Register for one.

Nursing Pillow Covers - You'll want your pillow to be pretty. You'll be looking at it a lot. Most moms find that 2 covers is enough. They are washable (for obvious reasons).

(2oz Bottles) - If you plan to bottle feed pumped milk at any point during the first month or two of your baby's life you'll find use for small bottles. They are also helpful later on for freezing small amounts of extra milk that you pump.  

(4-5oz Bottles) - If you plan to bottle feed pumped milk at any point in your baby's life, then stock up on these bottles. If you work outside the home then the more of these that you have, the better. Invest in the bottle type that is compatible with your pump. That allows you to pump into the same container that you feed from. 

8-11oz Bottles - Babies don't need these large volume bottles. Many parents use large volume bottles to feed their toddlers water, juice, and cow's milk. By the time that your baby is large enough to handle 8oz bottles he or she will be old enough for a sippy cup. 

(Sterilizer Bags) - These things are awesome! They're great for sterilizing pump parts at the end of the day. They can also be used with bottles and bottle parts. If you work outside the home I'd call it a must. Stay-at-home moms may not see much need for them unless they pump often.

(Slow Flow Nipples) - Breastfed babies who take breastmilk from a bottle will use slow flow nipples. They generally don't need to graduate to faster flow nipples. Don't bother registering for anything other than slow flow. There's a good chance that slow flow alone will be enough. Faster flows are generally needed for formula fed babies. 

Medium Flow Nipples

Fast Flow Nipples

Formula - If you plan to breastfeed then don't buy formula. You'll probably have formula samples sent to your door, so keep those around if having an emergency formula supply makes you feel better. 

Bibs - Babies are messy eaters! They also drool a lot. My kids' daycare uses bibs whenever they feed babies. It cuts down on outfit changes from post-feed spitting up.  

Burp Cloths - Babies spit up. Breastfed babies are not an exception to that. In the first 6 months of your baby's life you should keep cloths everywhere: bedroom, living room, diaper bag, in the car, and anywhere else your baby may be during or soon after a feeding. You can get these cheap, so it's a nice thing to put on your registry for people who may want to get you something small. Keep in mind that receiving blankets make awesome burp cloths.  

(Pacifiers) - If possible, avoid pacifiers for the first 4 weeks of your baby's life. Breastfed babies tend to enjoy pacifiers a bit less than their formula fed counterparts. It's your call on if you offer the pacifier or avoid it. It's your baby's call if he or she takes to it. Consider registering for 1 or 2, but don't stock up in case your baby isn't into them.

High Chair - Get one that's easy to clean, easy to move around your kitchen, and looks nice. 

(Bottle Warmer) - There are a few ways to warm a bottle of milk safely. One is to use a bottle warmer. Alternatively, you could put the bottle in a bowl of warm water or leave it out at room temperature. It doesn't matter what you do, as long as you don't microwave it. 

Toddler Plates/Bowls/Utensils - When you are pregnant and planning for a newborn this may seem like a silly thing to register for. The future you of 12-18 months from today will be super grateful that you registered for this. So be brilliant and put it on your list.

Sippy Cups - Get a few different basic types to start. Introduce it to your baby at 6 months to get him or her used to it. Most breastfed babies tend to like to drink more from cups rather than bottles as they get older. Don't stock up until you know what kind of cup your baby likes.

Swing - Both of our kids loved the swing. Therefore, we loved our swing. 

(Bouncer) - It's nice to have a place to put your kid down when you need to get stuff done around the house. Also, these are good for keeping your baby upright after feedings before he or she can sit up.

Playard - These things can function as a bassinet, changing table, travel crib, and older baby containment device. They're great for travel, filling in for all the stuff you have at home that you can't haul with you.

Playard Sheets - I didn't even realize that they made these. I didn't miss them. You can wipe down a playard pretty easily. 

Diapers - It's up to you if you go for cloth or disposable. Either way, you'll need a lot of them. 

Diaper Pail - I can't imagine not having one. We have two. I know some people opt out, but I'll never really understand that. I need a place to throw away diapers that will hold a lot and contain the odor.

Diaper Pail Refills - You'll need a lot of these during your baby's life in diapers. Stock up.

Diaper Cream - I'm not a big believer in diaper cream. If your baby has a rash then you can pick some up and use it. Not all babies need it. 

Wipes - Yup, wiping baby's butt is part of the job.

Wipe Warmer - I think I've met one person in my whole life who found this useful. 

Portable Changing Pad - Get one. It's a thing to put in your diaper bag that you unfold to change your baby on. Your diaper bag may come with one. Get the type that you can easily store and easily wipe down.

(Baby Bathtub) - I like our baby bathtub. If you don't want to get one then you'll have to bathe your baby in the sink. It's up to you. 

Towels - Your freshly-bathed baby needs to be dried off. A regular bath towel will work, but it's a bit bulky for the job. They're cheap enough to put on the registry, and you'll probably use them.

Washcloths - They're cheap and you'll use them. 

Baby Soap - Identify a baby soap that works as a shampoo and body wash. It's just easier that way. 

(Grooming Kit) - A baby hairbrush may be helpful. The comb is less so. The nail file and clipper may come in handy. On the other hand, babies look plenty cute without grooming. It's your call.

First Aid Kit - Accidents happen. Make sure that you at least have a bandaid. Buy one if you don't have one. And buy it now. I don't really know why people without kids would somehow not need basic first aid supplies at home.

Furniture Wall Straps - Children can pull furniture down on themselves, sometimes with tragic consequences. This is an easy step to forget. Do it now.

Babyproofing Stuff - You will thank yourself in 6 months for getting this stuff now. Do it little by little. Most of us babyproofed in a panic the first day that the baby crawled over to outlet by the edge of the stairwell.

Toys - Babies are not just eating machines. They're fun too! It's nice to have a few toys around. It's really exciting when they first start to care about them. 

Exersaucer - Great toy. Happy baby. 'Nuff said. 

(Bassinet) - When your baby is first born you'll want him or her to be in your bedroom with you for easy overnight nursing. The baby sleeping can happen in your room in a crib, playard, or bassinet. Any safe sleeping surface will work. I liked our bassinet. Use whatever you like. 

Bassinet Sheets - You can do without them. If your baby spits up in the bassinet you can just wipe it down. You'll have enough laundry to do.

Infant Car Seat - Your baby needs a car seat. The infant seats are nice so that you can remove a sleeping baby from the car without waking him or her. It's worth it. 

Convertible Car Seat - You can technically put a baby in these seats from birth. If you use an infant car seat expect to make the transition around your baby's first birthday. Look for a seat with a high weight limit. A good seat will rear face up to 40lbs or greater and forward face up to 65lbs or greater. A seat that grows with your child is a good investment. 

Stroller - Strollers are useful. Rarely do I meet a parent who doesn't find a stroller useful for at least some aspect of living life with a baby. 

(Carrier) - You can survive raising a baby without doing any babywearing. However, babywearing is fun and convenient. 

Diaper Bag - You'll need something to help you haul all the stuff you need for your baby. You can splurge on an expensive bag or you can opt to use a simply tote bag or backpack instead. 

Crib - I always recommend a safe sleep surface for babies. While there are some crib alternatives, I found a crib necessary for my kids.

Crib Mattress - Simple: if you have a crib you need a matress.

Crib Sheets - See above.

(Changing Table) - You'll need somewhere convenient to change your baby. Go for a changing table with some nice built in storage or place a changing pad on a dresser. 

Dresser - Find a high quality dresser for your child and he or she will have it for all of their childhood, perhaps for life. The dresser that sat in my nursery is now the main dresser that my husband and I use in our master bedroom. Bonus: it was a hand-me-down from a relative.

(Crib Bumpers) - Avoid them in babies under a year old. After a year of age they can be helpful to prevent your baby from getting arms or legs stuck in crib slats.

(Quilt) - Blankets and quilts are not recommended for use in cribs of babies under a year of age. However, babies over a year of age use them. If you're buying or making a blanket or quilt think about getting one that is sized for toddler and early childhood years.

Changing Pad - This are of great use as a surface for changing a baby. It can be moved to different locations around your house and can turn a variety of surfaces into a makeshift changing table as needed.

(Changing Pad Covers) - You have 2 options. Either you can use your changing pad without a cover and clean it regularly or you can get a cover (or multiple covers) and wash the covers often. It's up to you. Covers can be soft and pretty but they are optional.

(Monitor) - Some parents couldn't imagine baby care without their fancy video monitor. Some parents don't care. We used a simple audio monitor with our daughter. We occasionally use the audio monitor with our son. Honestly? We could live without it. 

Hamper - You need a hamper to collect all the dirty baby clothes. And there will be a lot of dirty baby clothes. 

Hangers - Have lots of little baby clothes? You'll need lots of little baby hangers. Then again, if you're ok with stashing all your baby's clothes in the dresser instead that's ok.

(Swaddler) - Both of my kids hated the swaddle. All those parents who say that swaddling helped them survive the newborn weeks and saved their sanity? I can't relate. But then again, it may save your sanity. Try swaddling your baby with a blanket first and if he or she likes it go for the swaddler.

Onsies - You will need a ton. Your friends and family will probably buy you a ton. Babies live in onesies. 

Sleepers - My kids lived in nothing but sleepers and onesies for the first year of their lives.

(Gowns) - Can be helpful for nighttime sleep.

(Sleep Sacks) - Can be helpful for nighttime sleep and naps. 

Mittens - I'm going to be honest, I never understood the baby mitten thing. Call me a bad mother, but I just let my kids scratch their own faces when they were babies. Neither gouged an eye out and it didn't seem to bother them.

(Socks) - Socks fall off. They are cute. But they fall off. You can live without them.

(Booties) - They are cute, but you can live without them.

(Hats) - They are probably helpful if you live in a cold climate. 

Pants - Babies can wear pants. But they don't need to wear pants.

Tiny Shoes - I had a rule where I didn't put my kids in shoes until they were starting to walk. Shoes are cosmetic in tiny babies. 

Dresses - Do you have a baby girl whom you want to dress up in a frilly dress? That's cool. But it's not needed. 



*Keep in mind that these are all based on my personal opinions as a mother and breastfeeding professional. You may disagree, and there's nothing wrong with that. Follow your own parenting instincts; different strokes for different folks

All Milk is Breastmilk

The normalization of breastfeeding is a hot topic these days. As well it should be. Breastfeeding is healthy and natural. It's good for both mother and baby. It's feeding the way that nature intended. It's not about shaming women who don't breastfeeding (at least it shouldn't be). It's about allowing women the freedom to celebrate the breastfeeding that they choose to do.

It's unfortunate that we have to normalize something that is so normal that it's part of what defines our species. Humans are mammals. Mammals are animals that feed milk to their young. Milk is, by definition, the liquid food that mammals (including humans) feed to their young. 

All real milk is, by definition breastmilk. 

Cow's milk is cow breastmilk.

Goat's milk is goat breastmilk.

Almond milk is........not almond breastmilk. 

Actually, it used to be that makers of soy milk, rice milk, and almond milk were barred from using the word "milk." They had to call it "almond beverage." Because it's not milk. 

What we commonly refer to as breastmilk is more accurately defined as human milk. Because humans make milk. It's what we do to survive as a species. Humans need human milk. And if human milk is unavailable, we need a substitute that is as close to human milk as possible.

So who needs cow's milk? Calves do. But if you're a human who likes cow's milk, that's ok too.

What do I pour on my cereal in the morning? Lowfat vanilla soymilk is my favorite. Even though it isn't really milk.


Mommy Wars

I hate the mommy wars.

I really hate the mommy wars.

I hate them as a mother. I hate them as a breastfeeding advocate. I hate them as a physician. I hate them as a human being.

The mommy wars are ugly. They are the embodiment of how mothers go all judgmental on each other for just trying to go about their daily business. I can assure you that if I posted to a blog, facebook page, or other forum about the simple day to day facts of how I parent, I would be torn to shreds. Verbally, that is. Why? Because the mommy wars are everywhere. And they suck. 

In a perfect world the mommy wars would disappear. But you and I both know that that isn't going to happen anytime soon. So let's take it a step at a time. And the first step that I would take is to remove breastfeeding from the mommy wars. 

Let's stop pitting breastfeeders against bottle feeders. Let's stop talking about breastmilk vs formula like it's some old rivalry to be fought. No matter what your position, each time that we engage in this fight we lose. We all lose. Because we first lose when we hurt each other. Then we lose because we intimidate and frighten women - not a good way to start a healthy breastfeeding relationship. Then we lose when we try to break up the fight with the solution that makes me cringe, "formula feeding, breastfeeding, whatever.....it's doesn't really matter."

It does matter. And how you talk about it matters.

Breasfeeding mothers and formula feeding mothers should be able to talk to one another about infant feeding. Why?

Because we need formula feeding mothers. Formula feeding mothers are really important to the success of breastfeeding.

 Let's say that you're looking for a way to get more women to breastfeed. Sure, you could march around town with a sign saying, "formula is poison." But, I'm sorry, that's just crazy. And it doesn't help anyone. You could sit down with breastfeeding moms and ask them about their experiences. That would be valuable, but that's only a small part of the story.

If you were to sit down with formula feeding mothers and ask them about breastfeeding, you would learn an awful lot. You may not like everything that you hear, but if you approach it with an open mind, it will help you a great deal. 

Women don't opt out of breastfeeding because they are evil. Women opt out of breastfeeding for many reasons. And often those reasons are failures of an unsupportive society or an unsupportive medical community. Or the reasons stem from misunderstandings propagated by a society that doesn't talk openly about breastfeeding. While we're busy playing a blame game we're glossing over some critical feedback. This group of moms is the most qualified to tell us what we could be doing better to make breastfeeding more accessible to others.

That is what my book is about. It's about presenting the facts and doing everything in my power to keep the facts free from judgement. It's about helping women understand the ins and outs, the ups and downs. It's about understanding why women don't breastfeed, so that we can come together and help empower more women to breastfeed.

Marriage Equality Day

Happy Marriage Equality Day for all my readers in same-sex marriages and partnerships! Today the United States recognized same-sex marriage nationwide.

In honor of today I'd like to share an excerpt from my book. While all breastfeeding mothers, regardless of relationship status, will find pearls of wisdom throughout the book, moms co-parenting with other moms will want to reflect on some special considerations. For some, being a breastfeeding mom co-parenting with another mom can be a bonus in the world of milk-making:


 As a mother parenting with a female partner you have the unique opportunity to decide whether or not both of you would like to breastfeed. Perhaps you have already decided that you will both breastfeed. Perhaps only one of you wants to be the breastfeeding mom while the other takes on a supportive role in the feeding process. Maybe you haven’t thought about your breastfeeding roles yet.

    If you and your partner are adopting your child and plan to breastfeed, then one or both of you will need to induce lactation. In this case, there is a distinct advantage to convincing your partner to breastfeed along with you. Two breastfeeding mothers means twice the volume of milk for your baby. This also gives both you and your partner the bonding experience of breastfeeding, a particularly desirable experience since you will both be eager to help your little one adjust to a new family.

    If you and your partner are becoming parents by having one of you give birth to your baby, then the roles in terms of nursing will be more clearly defined. For the sake of example I will assume that you are the mother who will be pregnant (the gestating mother), though the situation could just as easily work with the roles reversed.
During your pregnancy your breasts will go through the normal changes that I described in the previous chapter. When you give birth, your body will be ready to start milk production. Unless you have a particular reason not to breastfeed, you should nurse your child. If your partner does not feel comfortable breastfeeding then she will take on the supportive role in the breastfeeding process. This does not make your partner a lesser parent; she will have plenty of important responsibilities in caring for you and co-parenting your child while you breastfeed.

    If your partner plans to induce lactation then she should time this strategically around your pregnancy. If she is using hormones then she should start them as soon as possible when she learns that you are pregnant. She should stop the hormones about two months prior to your due date. Her goal should be to have her production up to the highest level possible prior to your baby’s arrival. 

    No matter how you and your partner plan it, you may find yourselves in an advantageous position of having two nursing mothers available for one hungry baby. This helps take some pressure off of you. But don’t let that lull you into a false sense of security; remember that your milk supply is based on a system of supply and demand. If you and your partner split breastfeeding duty equally between you, then you will find that you each have half the normal supply of milk. To avoid this situation, you will have to pump each time that your partner nurses in order to keep your own supply up. You and your partner should discuss your nursing strategy in advance to avoid low supply or stressful misunderstandings after your baby arrives. One popular strategy involves having the gestating mother nurse often while the non-gestating mother either primarily or exclusively pumps her milk.



Nursing in Public - Discreet or modest?

You're out and about with your baby. It's time to eat. Should you cover up? Good question. It's a rather tired debate. While some would argue that you're obligated to cover up when nursing, the choice is yours. And either choice is just fine.

Many women who choose to cover up do so because they want to be discreet. While I certainly don't object to the choice, I do object to the reasoning. Using a nursing cover is less discreet than opting out of the cover. Think I'm crazy? Hear me out.

Covering up is about modesty rather than discretion. Whether you use a nursing cover or a baby blanket, the purpose of covering up is to avoid exposing your breast in public. If your personal or cultural sense of modesty requires that you cover your breasts at all times, then covering up is the way to go. Nursing in public with a cover ensures that no one will see your breasts.

Being discreet is not about modesty in skin exposure. Being discreet is about nursing in such a way as to keep those around you from realizing that you're nursing. Covering up makes it more likely that people will notice you nursing. It's not that you're being too flashy or showy with it. It's simply that a large blanket or cloth draped over your body is likely to draw more attention to you than if you didn't have what is essentially a somewhat unusual garment on. Furthermore, a nursing cover is a garment/accessory with one purpose: to aid in modest nursing. Therefore, wearing a nursing cover provides a clear message that you are nursing. 

What about nursing in public without a cover? It will likely expose more skin. However, it allows discreet nursing. People passing by will see you holding your baby close to you. Some people may look closely enough to realize that you're nursing, but it's easy to miss. 

If you know that you feel most comfortable covering up (or not covering up), then it doesn't matter what is most modest or most discreet. Breastfeeding is beautiful and natural. There's no shame in nursing however you see fit. But if you're on the fence about whether or not to use a nursing cover, consider what your goals are in terms of nursing in public. Is it more important to you to conceal your breasts or to decrease the likelihood that others will notice you nursing?

Or you can choose not to care either way and make the decision based on what feels most natural for you to do. 

The Milk Shaking Controversy

Recently I ran across a blog post with some mis-information about shaking breastmilk. I figured it was time to clear the air. Below is an excerpt from Your Breastfeeding Guidebook explaining the controversy - myth and truth.

Should you shake the milk? Believe it or not, this is a controversial subject. In fact, the more you breastfeed the more you will get used to a lot of seemingly simple things becoming controversial subjects. There has been an objection raised by some in the lactation medicine community that shaking milk will cause the proteins in the milk to denature.

Denature? Huh?! Allow me to simplify it. Lots of the stuff that makes up our bodies (and your baby’s awesome magic breastmilk) is made of protein. Proteins are large molecules containing strings or chains of amino acids. These large molecules will twist, fold, turn, branch and scrunch together in very specific unique ways. The way that these proteins connect and orient themselves is critical to how they work in building muscle, killing bacteria, or doing whatever function that they are designed to do. If you denature a protein that means that you take away its natural form. If a protein is out of its correct form then it will not work very well or, in most cases, not work at all.

How did you like that biochemistry lesson in one paragraph? Hopefully you’re still following. The main issue here is the question of how difficult it is to denature a protein. The answer to that question is highly dependent on the protein. Proteins can potentially denature when exposed to heat, cold, acid, base, mechanical force, and a number of other things. The key word here is potentially. There are some proteins that are so delicate that you have to carefully regulate their temperature and handle them only with gloves in special containers in a lab. There are other proteins that you can literally set on fire and they would be just fine. The theory is that proteins in breastmilk are delicate enough that shaking would denature them. Therefore, some experts have concluded that breastmilk should be swirled very gently and not shaken with any level of force.

I have a few concerns about this conclusion. First, there are no published peer-reviewed scientific studies that I can find that review mechanical force as a mechanism for denaturing proteins in human milk. Second, in order for protein denaturing to be significant, studies would need to show that shaking does more than just denature proteins. They would have to prove that shaking denatures a significant quantity of biologically relevant proteins, and that losing those proteins makes the milk inferior to non-shaken milk.

Third, expressed milk has to routinely endure other potentially denaturing forces that we seem otherwise unconcerned about. All milk is forcefully removed from the milk ducts of your mammary gland through a small opening in your nipple. The milk is then filtered through a mechanical pump where it is again agitated. It is then placed in some type of container and carried in a bag or cooler. While in that bag or cooler the milk is agitated by movement, such as a busy working mother walking to a parking garage or going over bumps while in the car. The milk then may be transferred to and from other containers thus causing it to undergo more agitation. Milk may then experience thermal pressures: cooling, freezing, and rewarming. The milk then is fed to your baby by being squeezed through a tiny hole in an artificial nipple. It is then swallowed, where it goes into your baby’s stomach, where it is exposed to squeezing and hydrochloric acid.

I don’t see any evidence that gentle shaking is any more harmful to milk than the other forces that milk experiences in its pumped life. I agree that vigorous shaking is not necessarily the best idea, but that’s for a different reason. When you vigorously shake milk you will introduce air into the milk. If your baby swallows too much air, then he or she may develop excessive gas. This may not bother an older baby, but very young babies tend to be more sensitive to gas. Also, since we have no studies to refute the theory, it is possible that vigorous shaking—the type that is out of proportion to typical agitation that milk experiences—may cause some protein change. Until we have more studies done that can tell us the truth about the amount of force that is appropriate when handling milk, shake or swirl milk lightly.

Nursing in Public - It's ok to say no.

You have the right to nurse in public. But more importantly, you have the right to decide whether or not you will nurse in public. This is a distinct and frequently misunderstood point. Nursing in public is a human rights issue, and it impacts women who choose not to nurse in public. 

In a future post I will address the topic from the angle of women who choose to nurse in public. Today let's focus in on the mother who chooses not to nurse in public. Why? Nursing in public is often seen as a benchmark for a truly liberated nursing mother: anyone can nurse at home, but only the best of the best will nurse in public. 

I find this problematic on a number of levels. First, the fact that nursing in public in considered a daring move at all is a reflection of the trouble with how our society views things. It's feeding a baby, not disarming a grenade. Second, by looking down on the mother who chooses to feed in private only, we are committing an act of hypocrisy. Are you morally superior by nursing in public? Not if you turn around and scowl at the bottle feeding mother the same way that the ignorant stranger scowls at you.

There are plenty of good reasons why a mother may opt out of nursing in public. These are just a few examples:

-She exclusively pumps for her baby

-Nursing in public is physically awkward (no nursing pillow, hard to find a good position to nurse in)

-Her personal or religious beliefs dictate a degree of modest dress where she is not comfortable partially exposing her breast

-She is not completely comfortable with the people around her and is nervous about nursing in front of them

-A previous experience with nursing in public resulted in some type of harassment

-Her baby is having difficulty latching, making an experience of nursing in public particularly stressful

If you decide not to nurse in public, there is nothing wrong with that. Nursing in public is a choice. It's a choice to be made by the nursing mother. It doesn't make you any less of a good nursing mother if you decide that nursing in public simply isn't right for you. You may one day change your mind. You may not. Either way, feel confident in your decision. And if you see someone else out in public feeding their baby in a way that's different from you, just respect their decision and move on.

The Freezer Stash: breastmilk storage containers

Welcome to my freezer stash.

Yup, that's my freezer stash, complete with neon stickers and all the bags and bottles in disarray. I love my freezer stash. Sure, it could be bigger, but I'm ok with it. It's my insurance policy, my security blanket, and something that I'm getting ready to lean on a bit more heavily. My days of being home all day with my baby are numbered; it's almost time to return to work. 

The return to work is a big milestone for the breastfeeding working mom. The first time I took this step it was a big mix of emotions: stir crazy from being home, nervous about putting my tiny one in daycare for the first time, and just not sure how the whole balance of working mommyhood would go. This time I feel more balanced and confident, allowing me to focus on what got lost in the shuffle last time: the freezer stash.

Working and pumping is all about the stash. It's about finding a way to keep the milk plentiful enough to keep up with a hungry baby while you're away at work. If you're lucky you can keep up and not feel nervous that the well will run dry while you're in the middle of wrapping up some important work project. Building the stash is also about choosing your storage containers. When choosing storage containers you need to consider cost, convenience, and averting disaster.

Plastic Bottles: These get high scores for convenience. You can pump directly into them (provided that they are compatible with your pump or you have an adapter). You can store in the refrigerator or freezer. They virtually never leak or crack. Plus, when it's time to feed there's no need to transfer your milk to another container. On the other hand, they require washing and disinfecting. They also take up more space than bags do.

If your stash is small, then cost is not much of an issue. However, keeping a large freezer stash in bottles could get expensive. 

Medela 2oz are about $1/ea. Medela 5oz are about $2/ea. Medela 8oz are about $5/ea.

Avent 4oz are about $7.50/ea. Avent 9oz are about $6.50/ea.

Hygeia 4oz are about $5.50/ea.

To store 100oz of a freezer stash in Medela 2oz bottles it will cost you $50 to buy those bottles. 

Storage Bags: When I first started breastfeeding my daughter I had no clue what on earth these things were. Now I've warmed up to them a bit more. They are not quite as convenient as bottles in the sense that you (with one exception that I will mention later) cannot feed you baby directly out of them. You may be able to pump directly into them, but most women end up pumping into a bottle, pouring into a bag for storage, and then pouring into another bottle for feeding. The danger is that with all the pouring there's risk of spilling and milk being left behind. And, of course, there's always the dreaded possibility of the leaky bag. Some experts warn against their use because the possibility of leakage means a possibility of contamination. However, most babies can consume milk stored in bags safely.

Yikes! With all those cons you would think that most mothers would steer clear of bags. Yet, you will notice that my freezer stash has bags in it. Not to mention that fact that many nursing moms love the storage bags and store milk in them almost exclusively. Why? First, they are space savers. You freeze them flat and they hardly take up any room at all. Second, they are cheap. For Lansinoh they are $0.16 per bag and for Medela $0.22 per bag. Bags can hold up to 5-6oz, so it's easy to see why bags are the storage option of choice for a large freezer stash. 

Finally, storage bags are disposable. This is a bad thing if you shudder to think of all the waste from discarded bags. This is a good thing if you are happy to choose a storage option that doesn't require cleaning.

Glass bottles: These are the storage option of choice for mothers who don't trust plastic. They are good for the environment, and some studies suggest that they may preserve breastmilk better than plastic storage containers. However, most glass containers can't go in the freezer, and even freezer-safe glass containers cannot be cooled or warmed too rapidly, lest your container burst, leaving you with wasted milk and, to add insult to injury, glass shards to clean up. You can pump directly into some glass bottles, but you may find this awkward since glass bottles are heavy. Also, glass is pricey. Freezer-safe Lifefactory bottles sell for over $10 per bottle. Other brands are cheaper than Lifefactory, but most are still more expensive than their plastic counterparts. 

If you have a problem with plastic, then glass is the way to go. However, don't count on being able to build a large freezer stash with your glass bottles. If you need to use glass and you want a freezer stash, then you will need to invest in some small freezer-safe glass mason jars or food storage containers.

Storage bags that you can feed from: This was a new one to me recently. The company doing this is called Kiinde. They sell storage bags that you can pump directly into using an adapter. You can refrigerate or freeze the bags and then twist them into this bottle-like device with a feeding nipple. Bags are single use and cost about $0.32 per bag.  It seems like the best of both worlds if you like aspects of both bags and plastic bottles. I can also see it as a brilliant way for the company to make money. If you buy the bags, then you need to buy the bottle ($7.50 ea), nipples ($6 ea)*, and adapter ($7). At that point you might as well invest in the whole kit ($38). And if you have the bottles and nipples then you'll need to keep buying the (disposable) bags, ensuring that you continue to spend money on Kiinde products. 

There's more than one good way to store your breastmilk. Pick the option that's most convenient and affordable for you. 


*I find it interesting that the slow flow nipples are more expensive than the medium or fast flow. Most breastfed babies use slow flow for most of the time or all of the time that they are nursing. Why would a premium be charged for the breastfeeding baby's nipple? No clue.

How to Be a Breastfeeding-Friendly Physician

In my book I discuss strategies for finding a breastfeeding-friendly healthcare provider. This is an important step on the road to breastfeeding success. But it occurred to me - why not give you the story from the other side of the glass? Let's take a look at what it takes to become that breastfeeding-friendly doctor. 

Believe in breastfeeding. I mean really believe in it. Believe in it the same way that you believe in eating healthy, exercising, and not smoking. Sure, not all your patients are going to do it, but fewer of them will do it if they don't believe in it. And why should they believe in it if you don't? If you're not convinced then it's time for you to do a literature search of studies that support breastfeeding. 

Get to know a lactation consultant. A good lactation consultant is your most important ally in your efforts to support your patients in breastfeeding. International Board Certified Lactation Consultants (IBCLCs) undergo specialized training in lactation medicine and are certified to have experience helping women and their babies breastfeed. Most IBCLCs are thrilled to connect with a physician enthusiastic about breastfeeding - the topic that they have dedicated their careers to. A good way to get a foot in the door and build good will is to shadow for a day with the IBCLC at whichever hospital you are associated with. Once the relationship is established it will be mutually beneficial. One regret that I have about residency is that I didn't use my elective time to do a rotation with the hospital lactation consultant. I would have learned a lot. 

Don't be afraid of medicating nursing mothers. As a medical doctor it is your responsibility to appropriately treat your patients, and sometimes this requires the use of medication. Some doctors tell nursing patients not to take any medication ever. Don't be this type of doctor. Evaluate your patient. Choose the correct medication. Use it if you know that it's safe. If you don't know then look it up. Invest in a copy of Medication and Mother's Milk (or get an online subscription). Become familiar with the LactMed Database. Both are excellent resources. Worried about liability? Documentation is everything, and quoting reliable references will help you accurately counsel and document the risks and benefits of your treatment plan. 

Become familiar with common infections related to breastfeeding. Know how to recognize and treat mastitis. Understand nipple thrush. Ever heard of Raynaud's phenomenon of the nipple? If not, then take some time to look it up. There are effective treatments for these painful conditions, and your patient will likely need a prescription from you. If you get stuck on what to do then call your IBCLC. 

Learn about low supply. Inadequate milk supply is a huge topic in lactation medicine. The most commonly cited reason for a women to stop breastfeeding is perceived low supply. Not all women who stop for this reason actually have low supply. You are the diagnostician, and you need to figure it out. Inadequate supply is diagnosed when there are signs of inadequate intake: poor growth or dehydration. When true low supply exists the treatment is multi-fold. You want to get the baby fed, maintain breastfeeding whenever possible, and keep the mother's confidence and sanity intact. It's a tall order, but it's what needs to be done. Again, having an IBCLC to lean on helps.

Use formula judiciously. Formula is like a knife. Used properly, it's a vital tool. Used improperly, destruction may ensue. If true low supply exists, formula supplements can help a mother feed her baby while she works on boosting her supply. Remember that formula that replaces feedings can hurt a mother's supply. Supplementing with pumped milk should take priority, and whenever you can supplement at the breast you should do so, especially early on. Advising a breastfeeding mother to switch to exclusive formula feeding is a rather extreme measure, so think through it carefully. If there is a way that she can still safely breastfeed you should pursue that option. 

Don't be too afraid of jaundice. You and I both know that jaundice can be scary. We also know that jaundice can be normal. Whatever plan you come up with for managing a concerning case of jaundice should involve a way to maintain breastfeeding. If formula is not absolutely necessary then try to avoid it (see above).  

Create a breastfeeding-friendly atmosphere in your office. Invite patients to nurse in the waiting room or exam room. Advise your staff to be welcoming of nursing mothers. Don't force anyone to cover up when nursing, but offer a private area if requested.

If you follow all of the above suggestions you will stand out from the crowd as a breastfeeding champion. You don't want to be "that doctor" who the breastfeeding mother or the IBCLC complains to her friends about. Instead you can be the person who helps a mother reach her breastfeeding goals.


How to Get a Breastpump through your Insurance

With the passage of the Affordable Care Act (ACA), more insurance companies are offering free or low cost breastpumps as part of their preventative care coverage. No matter what your political views about the ACA, it's nice to be able to get a free breastpump. You'll want to take full advantage of this benefit. But how? 

The first thing that you'll need to do is call your insurance company. Ask them the following questions:

- Do you cover breastpumps?

- Will I have a copay for my pump? If so, how much?

- Is there a particular company that I need to order my pump from?

- When should I order my pump? Will the pump be shipped right away or do I need to reach a certain point in my pregnancy before it arrives?

- Do you need documentation from my doctor in order to get a pump?

Most companies cover pumps, but there are some companies that were grandfathered in, meaning that they are being allowed to deny women this benefit. Most will provide the pump for free, but some require a small copay. Don't let the copay trouble you too much since the cost of a copay is lower than the out-of-pocket cost of a new pump. 

Once you have all the information that you need you can start figuring out where you'd like to order your pump from. Insurance companies will not reimburse you the full amount of what it would cost to get a pump from a regular store. Why? Because insurance companies contract with durable medical equipment (DME) companies to get low prices. These DME companies purchase pumps in bulk from the manufacturer and then sell them at a low cost through insurance companies. 

Once you have identified the DME company that you plan to use, you can order your pump. With most companies you will order your pump online. They generally have user-friendly websites and are more than happy to help you with your order. Go to the website and fill in your information. After you've entered basic information and the name of your insurance company you will see a list of available pumps. Most companies will offer you the option of several different brands. Do your research and pick the pump that best suits your needs.

After ordering your pump your wait to receive the pump is based on a number of factors. Some insurance companies will only send the pump after you reach a certain point in your pregnancy. If you order the pump at 20 weeks but your insurance company only pays after 32 weeks then you will simply have to wait until you reach 32 weeks to have the DME company ship the pump to you. Also, some insurance companies require physician verification prior to getting the pump. Your OB or primary care doctor may need to write a prescription for a pump, write a letter of medical necessity, complete a form, or some combination of the above. The DME company will typically take care of contacting your doctor for you, but if your doctor is slow to respond then you may need to reach out to him or her. 

Hopefully this whole process goes smoothly (it usually does), and in no time your pump will arrive at your door. When it arrives don't be too disappointed when you discover that your pump is just a pump. Insurance issued pumps generally come without a carrying case, cooler, or any accessories. Some DME companies will offer you the option of ordering the carrying case and accessories at the same time as ordering your pump. Of course you will pay out of pocket for these items.

Ordering a pump through your insurance may be a bit of a pain, but it will save you a fair amount of money. Follow the instructions above and your ordering experience should move along smoothly. 


Natural Birthing and Breastfeeding: myths and facts

If you spend some time looking at books and websites about breastfeeding you'll notice a pattern. An alarming number of them have a strong opinion on how you should birth your baby. And that strong opinion seems to be that in order to not completely destroy your chances at breastfeeding success you should birth your baby naturally. 

This immediately brings two questions into my mind. First, what the heck does it mean to have a "natural" birth? Second, what does this supposedly perfect birth do to help with breastfeeding?

From what I can gather, advocates for natural birthing have several criteria for a natural birth. All natural births should be vaginal births. C-section births are automatically excluded. Natural births should start spontaneously, so inductions are eliminated too. Natural births are drug-free. To go completely natural with your birthing you should skip the epidural. Some say that a natural birth should occur outside of a hospital and should proceed with no interventions. 

Why the association between natural birth and breastfeeding? There's some bias at work here. Breastfeeding is natural feeding, so it follows that advocates for natural feeding may also be advocates for natural birthing. In other words, if you're the sort of person who believes in the natural birth concept chances are pretty darn good that you're into breastfeeding too. If this describes you then there's nothing wrong with that. However, we have to be cautious when we take two related concepts and start linking them together however we see fit. 

So are the supposed benefits of natural birthing just a ton of malarkey?  Let's look at it a bit more closely. Vaginal delivery is the preferred method of delivery. It spares a mother having to recover from a surgical procedure while she is breastfeeding. Mothers who give birth via C-section start milk production a bit more slowly than mothers who give birth vaginally (we're talking maybe 12-24 hours difference). Pain medication that is given to a mother during labor can transfer to her baby via the placenta. These medications may make a baby more sleepy and lead to difficulty with latching and less interest in breastfeeding. 

At this point it seems that natural birthing is the way to go, but let's not be too hasty with that conclusion. Natural birthing, like most things in life, comes with its share of benefits and risks.

Vaginal delivery is the preferred method of delivery. That is a well-established fact in the medical community. It follows that a C-section should be done only in cases where vaginal delivery is impossible or too risky to justify trying it. In other words, women get C-sections because they need them. If your doctor recommends a C-section and you say no then you are taking on the risk of that decision, which may be deadly for you or your baby. Elective C-sections are rare, and women are generally only asked to choose between a vaginal delivery and a C-section in the case of a prior C-section (that is another rather big topic in and of itself).

Labor induction is somewhat murkier. Elective inductions are fairly common and come with their own risks. However, a good number of inductions are done for medical reasons. Low risk women will be offered an induction around 41-42 weeks to avoid the risks of a post-term pregnancy.  A pregnancy with complications may need to end with an induction at 39 weeks or sooner, depending on the situation. If you have a complicated pregnancy and refuse to have an induction you are putting you and your baby at risk. 

If labor induction is a murky topic then the topic of medical interventions during labor is murkier still. Some medical interventions are perfectly reasonable to skip. For example, if you want to labor without an epidural most doctors wouldn't blink an eye at that decision. On the other hand, refusing to get an IV placed is a choice that comes with some potential risks. Every intervention that you run across has 2 sets of risks: the risks of getting it done and the risks of not getting it done. 

If you are a natural birthing enthusiast that's ok. Choosing to have a vaginal delivery with little to no intervention  in the case of a low risk pregnancy is pretty reasonable. But go into it with your eyes wide open. Ask lots and lots of questions. Know all the risks, including the risk of refusing interventions. Talk to a trusted medical professional. If your natural birth goes smoothly then you'll probably do well breastfeeding, but there are no guarantees. You may still have difficulties.

What about if you don't have a natural birth? First of all, there's nothing that makes the experience of birth outside of "natural" circumstances any less legitimate. Most women in this country give birth under circumstances that are deemed less than the "natural" ideal. While medical interventions may introduce some complications to the breastfeeding experience, these complications are not atypical and can be overcome. C-section moms usually find it easiest to start nursing using a football or clutch hold that reduces pressure on the location of the incision. Babies are sleepy after pain medication, but it's not uncommon for babies to be sleepy in the first 24 hours of life no matter what and need some coaxing in order to latch.

 I believe that we need to stop talking about natural birth as a prerequisite to breastfeeding. It is distracting. When we talk about breastfeeding we need to focus on breastfeeding. Birthing choices are complicated and personal. They can be a source of stress for expectant mothers. Breastfeeding is for everyone, no matter how your baby happened to make the trip from womb to breast. Your birthing choices will not doom you to breastfeeding failure. And, most importantly, seek professional advice and always make the choices that are best for you and your baby. 

Formula Samples - to trash or not to trash?

Every now and then I'll run across a post on my Facebook page from a breastfeeding friend with the classic question, "I have some formula samples. What should I do with them? Anyone want them?" A similar post periodically comes up on breastfeeding advice forums, "I have formula samples. Should I trash them? What should I do with them?"

No, it's not wrong to want to throw out those formula samples. After all, if you're struggling with some aspect of breastfeeding, then it's rather infuriating that someone is shipping a box of formula to your door. It's like they're trying to talk you out of breastfeeding your baby: something that you want to do and are working hard to do. For many mothers they need to eliminate the temptation; they need to get the formula out of the house so that they don't feel the need to use it. And even if you make it through the early days with the formula samples still around, at some point it'll become clear that you just plain don't need it and will want to get it out of your house to clear the clutter.

So, yes, I understand why you may want to throw your free formula in the trash, but DON'T THROW FORMULA AWAY!

Why not? Why not stick it to those formula company fat cats trying to tempt you with their pricey product? I have a few reasons. Formula is real food, not poison. It is entirely reasonable and, in fact, recommended to use formula in cases where human milk is unavailable. If you struggle with low supply then you may need to feed your baby some formula. There is no shame in this. And it's ok to keep formula samples in your pantry just in case you may need them in the future. 

But what if you don't want to keep the formula around? 

Donate it! Always donate your formula samples. Yes, you could offer to give them to a formula feeding friend, family member, neighbor, or Facebook acquaintance. That's not a terrible solution. But before you start offering it around to people you know, seriously consider donating it. Why? Because some babies really need infant formula. Yes, you read that right. Formula is necessary in some cases, and donated formula can save lives.

Breastmilk is the recommended food for all babies (except in a few rare cases). If adequate breastmilk is unavailable, infant formula is the recommended breastmilk substitute food. For a variety of complicated reasons (some of which we as a medical community as still working to understand), low income mothers are at high risk of not breastfeeding. When a woman stops breastfeeding, her supply significantly decreases, eventually dropping to a point where she can no longer breastfeed without going through the process of re-lactation. In other words, while switching from exclusive breastfeeding to exclusive formula feeding can be done as a snap decision, making the switch in the other direction is not easy and sometimes impossible. 

So why should we care? Put yourself in the shoes of the low income formula feeding mother. You're struggling to raise a family with limited resources available to you. You may or may not be aware that breast is best, but that hardly matters to you at the moment since your milk supply disappeared weeks ago. You need to feed your baby, and formula is the only option that you have left. This means filling bottles with formula all day every day. You're buying can after can of the stuff, and it's not cheap. You buy the cheapest formula in the store, but even that is pricey. You sign up for WIC because you need free formula right now. Except that WIC is a supplemental nutrition program, meaning that the free formula from WIC won't be enough. So what are you going to do? You have a couple options. One is to water down the formula to make it last longer. Which you do because you have to. Except you're embarrassed to tell anyone that you do this, and no one has the opportunity to tell you that watering down formula can cause hyponatremia in your baby. And hyponatremia can cause seizures and, in extreme cases, death.

What other options does the low income mother have? Food banks. Church pantries. And whatever other charitable organizations provide food donations to the needy in your community. So donate your formula to her. Because she needs it. Would breastfeeding be better? Sure. One day we'll make breastfeeding feel more accessible to women like her. But in the meantime she's got to feed her baby and she needs help.  


Maternal Mental Health Awareness Day

I'm a day late on this one, but this is such an important topic that I would be remiss if I didn't address it. Yesterday was maternal mental health awareness day. It was a day to think about postpartum mood disorders and their impact on women.

Postpartum depression and postpartum anxiety are common, and they can create misery for women during a vulnerable and sensitive time in their lives. Raising awareness helps us as a society be more supportive of new moms.

If you think that you are experiencing postpartum depression then you should seek help right away. Don't be ashamed. You are not alone. There are effective treatments available to you.

Treating postpartum depression is important because untreated depression can be harmful to both mother and baby. There are a number of treatments that are safe during breastfeeding. Many nursing mothers are afraid to take medication, but it is better to treat your depression than continue to suffer because of a fear of medication.

Some have suggested that breastfeeding can prevent postpartum depression, but we know that breastfeeding doesn't prevent all cases of postpartum depression. Plenty of breastfeeding mothers suffer with the condition. Studies show that breastfeeding mothers are less likely to experience depression compared to their formula feeding counterparts. However, it is unclear whether or not this is due to any protective effects of breastfeeding. In other words, there is a correlation but no clear causation.

Most experts suspect that the connection has more to do with the stress that depression places on the nursing experience. Often depressed mothers find breastfeeding overwhelming. In fact, having trouble with breastfeeding may be a symptom of depression, particularly if these breastfeeding struggles are associated with guilt. Depression  can cause women to doubt their ability to parent and their ability to breastfeed. In other words, depression hurts a mother's self-confidence and makes her less likely to breastfeed and more likely experience feelings of inadequacy because of her difficulty with breastfeeding.

So remember, if you are struggling with breastfeeding then take some time to reflect on whether or not this is a symptom of underlying depression. If you are depressed then you should seek help. Treating your depression is likely to make breastfeeding and parenting a more positive experience for you.

Second Time Around

Breastfeeding is an adventure. It doesn't matter if it's your first baby or your tenth. There are surprises around every corner, particularly in those early days after your baby's birth.  While there's no guarantee that breastfeeding your second (or third or forth....) child will be better than breastfeeding your first, there are some distinct advantages to going into your breastfeeding relationship with some experience under your belt.

In my month-long experience of being a second time nursing mother, I've noticed a few things that make nursing the second time around better than it was when I was a novice:

1. After telling them that I had a daughter who nursed for over a year, the staff at the hospital never doubted my commitment to nursing my son. This meant that my nurses were happy to cheer me on and give me the space that I needed to nurse comfortably.

2. I was prepared for the learning curve of those first few days when the baby is still figuring out how to latch.

3. I was also much more prepared for my baby needing to nurse constantly all night long. 

4. Nursing in public is much easier this time around. I had over a year of nursing my daughter to practice and get comfortable with it. 

5. There was very little nursing clothing to buy. Most of it could just be dug out of storage.

6. Likewise, digging through all the storage bins in my son's nursery was like Christmas morning. There was a ton of stuff that I had forgotten about since my daughter weaned: breastmilk storage bottles, lanolin, and enough nursing pads to last me forever.

7. Second time nursing mothers are at lower risk for delayed milk production and low supply compared to first time nursing mothers. As a person who struggled with low supply with my daughter, it's nice to know that I may escape that fate this time around. (Though it's a challenge that can be overcome).

8. Confidence. It's a wonderful thing to pick up your baby and think, "I've done it before and I've got this."

Don't worry if you're a first time mother; you can breastfeed. We've all been there and we've made it happen. But if you're struggling, don't despair. It gets better. As the weeks and months go by you build your knowledge and skill.