So You Want to Be a Lactation Consultant

posted Jun 15, 2020, 1:08 PM by Carolyn Honea, IBCLC, CLC   [ updated Jun 15, 2020, 2:15 PM ]

So You Want to Be a Lactation Consultant

We receive emails weekly from people who want to become lactation consultants. In many cases it's a mother who had such a meaningful experience breastfeeding her own baby that she wants to help inspire others. Being a lactation consultant is a very fulfilling job. Every day you get to enter into the sacred space of a postpartum mother who is looking to you for comfort, guidance and reassurance. Of course, like any other job, it definitely has its challenges. One of the first challenges is the frustratingly complex and expensive process of becoming a lactation consultant.

There are many beginner certifications available that are obtained via online education or a 40 hour in person course. These are great ways to get some foundational breastfeeding knowledge and start you on your journey. However, to become an International Board Certified Lactation Consultant (IBCLC) you must have health science college classes similar to what you would take for a nursing degree, 95 hours of lactation education/lectures, and hundreds of clinical hours supporting breastfeeding families. After these requirements are met, aspiring lactation consultants will be eligible to sit the board exam for IBCLC. If you are already working as a healthcare professional in a related field (for example, an RN on a labor and delivery floor or a pediatrician's office) you may be able to complete the process in as little as a year. However, if you are currently in an unrelated field it often takes 3 or more years to fulfill the prerequisites to sitting the exam. You may have to piece together the requirements on your own as there are few all inclusive university based programs available.

IBCLC Prerequisites:
Health Science Classes - This usually includes biology, anatomy & physiology, infant and child growth and development, introduction to clinical research, nutrition, psychology, and sociology, among others. See this guide to review the requirements. Note: there is no time limit on when these classes were taken, as long as they are completed before applying for the IBCLC exam. Because of this, completing the health science classes is a great place to start.

Lactation Education Hours - We recommend the Certified Lactation Counselor Course and the Lactation Education Resources courses to begin gathering your lactation specific education hours. Note: these lactation education hours must be completed within the 5 years preceding the exam application. You'll need 95 hours covering the required topics so be sure to plan accordingly.

Clinical HoursThis hands on experience can be gained in a mentorship situation (500 hours required), a university based program (300 hours required), or a various other volunteer and clinical settings where there is accountability for time logged working with breastfeeding families (1000 hours required). (Note: these clinical hours must be completed within the 5 years preceding the exam application.) Gaining clinical hours is the most difficult part of the process for most people, as there are few contexts and opportunities to gain appropriate clinical experience. Some hospitals offer internships, so this is the best place to check first unless you can go through a university based program below. Another common route for clinical experience is through a volunteer organization such as becoming a La Leche League leader, BreastfeedingUSA leader, or WIC peer counselor.

The Exam - This four hour proctored board exam is offered twice a year and covers a wide variety of topics including but not limited to human lactation. Before sitting the exam, you'll need to apply a few months in advance and verify you've completed all the requirements above.

University Based Programs

University based programs combine the health science classes, lactation education classes, and hands on clinical experience into one package. Those closest to our area include Johnson C Smith University in Charlotte, Winthrop University in Rock Hill, University of North Carolina in Chapel Hill, and North Carolina Agricultural & Technical State University in Greensboro.

How We Can Help

At some point in the future, we may start to offer IBCLC mentorship programs to help you obtain clinical hours. The typical cost for participants in these programs is around $10/hour (keep in mind you'll need a minimum of 500 clinical hours). These clinical programs are similar to the clinical programs that student nurses would complete through their degree program, except that the clinical hours are provided in the context of our private practice. You can check back to this page to see if we are offering mentorships, or follow us on Facebook for announcements.

An additional way we can help is to provide shadowing opportunities for those seeking to diversify their current clinical experience. If you are a CLC or aspiring IBCLC we may be able to make arrangements for you to shadow us during lactation consultants to gain greater exposure to the diverse work we do. As private practice consultants, we get opportunities to work with babies of all ages and with a wider variety of needs than commonly seen the hospital context. The typical cost for these shadowing experiences is also $10/hour. Due to the current coronavirus pandemic, we are not offering shadowing opportunities at this time but you can check back here for updates on when this opportunity is available again.

Coronavirus Resources for Breastfeeding Families

posted Mar 15, 2020, 1:25 PM by Carolyn Honea, IBCLC, CLC   [ updated May 24, 2020, 5:39 PM ]

Lactation Support During the Coronavirus Pandemic

We are continuing to offer virtual consults and in-home lactation consults during the coronavirus outbreak. Breastfeeding is essential to the health and well being of mothers and babies, and it's never more important than during times of crisis or health emergencies. Breastfeeding provides food security. It is always readily available without needing a trip to the store or worrying about a shortage of formula. Breastfeeding is also psychologically protective for both mother and baby, as it provides hormones that promote relaxation and bonding during stressful times.

If mother contracts coronavirus, breastfeeding provides the infant valuable antibodies and protection. Past studies have found that formula-fed infants have triple the risk of being hospitalized if they have a respiratory illness. Although current reports indicate few infants are being hospitalized due to COVID-19, it would be expected that a disproportionate amount of the hospitalized infants are formula-fed. For this reason, the World Health Organization urges all families to prioritize breastfeeding if possible.

If you are experiencing any kind of infant feeding difficulty, please don't put off getting help. We are ready to support you now more than ever. Feeding your baby in a way that promotes the well being of the whole family is a worthy priority. Here are some steps we are taking to ensure the health of all the families we support:

Keeping Families Home

By offering home visits and virtual consults, families are not coming in contact with the germs that would be found in a hospital outpatient clinic or office. We are removing office consults from our online schedule, though families outside our travel area are still welcome to reach out to us directly for scheduling in our office ( We want to keep you safely nesting at home as much as possible.

Extra Sanitization Measures
During the pandemic, we will be taking extra steps to ensure the sanitization of everything we bring into your home, including wiping down our scale and other essential items with sanitizers. As always, we will wash our hands before working with you, wear gloves during infant exams and a mask. If any of our lactation consultants are symptomatic, they will contact you ahead of time and help you reschedule with another lactation consultant.

 Virtual Consults for Families with Illness
If anyone in your household has known exposure to COVID-19 or has a cough or fever, we ask that you reach out to us ahead of time so we can change your appointment type from a home visit to a virtual consult. Breastfeeding support is essential to the well being of a family even during a health crisis, and we would love to provide you video based support. We can assist with topics such as how to maintain milk supply during sickness, safe medications for breastfeeding mothers, strategies for reducing mother-baby transmission, tips for enhancing your rest, and guidance to ensure baby is thriving nutritionally.

A Word of Encouragement

Finally, we want to reassure you that the risk of serious illness for mothers and babies exposed to coronavirus is low. Although the media loves to draw attention to isolated anecdotal stories of infants who contracted coronavirus, these handful of cases represent about 1 in 1,000,000. In other words, your child is at much higher risk of suffering from RSV or SIDS than COVID-19. Most of the above precautions are primarily out of concern for spreading the virus to vulnerable members of the community such as grandparents. Grandparents should postpone their visit until the time of social distancing is past. To read learn more about breastfeeding and coronavirus please see the World Health Organization's recommendations on breastfeeding and coronavirus, the International Lactation Consultant Association's guidelines,
 and the La Leche League's website.

We are here for you. Please let us know how we can help.


posted Jan 11, 2020, 7:57 AM by Carolyn Honea, IBCLC, CLC   [ updated Jun 10, 2020, 4:31 AM ]

What is mastitis?
Mastitis is an infection or inflammation of the breast. Acute mastitis causes mothers significant breast pain and fever; breast redness, warmth, body aches and chills may also be present. The main difference between mastitis and plugged ducts is that plugged ducts only cause localized symptoms, whereas mastitis causes systemic symptoms  Mastitis can come on suddenly without warning (characteristic of bacterial mastitis), especially if you have cracked nipples that might allow bacteria to enter. Or, it can come on gradually following unresolved plugged ducts (characteristic of inflammatory mastitis). One study found that mastitis occurs 25 times more often in women who were given antibiotics in their third trimester due to the disruption of the breast's natural flora. Keep in mind all women are given intravenous antibiotics during csection deliveries.

There are many things you can do at home to support your immune system's response and feel some relief. However, please consult your midwife or OBGYN if your symptoms are not improving after 24 hours - antibiotics may be necessary.

This protocol emphasizes the importance of reducing swelling and inflammation with anti-inflammatories; strategies for loosening any plugs and improving breast emptying. Read more here.

Bed Rest
Until you are fever-free (without the use of fever reducing meds), we recommend bed rest with your baby for two reasons. First, your body desperately needs rest to fight off this infection. Staying off your feet and cozying up in bed give you the best chance to rest even if you aren't able to get much sleep. Second, spending a day or two focused only on resting and breastfeeding will give baby lots of opportunities help move the milk and relieve your mastitis. Frequent breast emptying is incredibly important to help your body fight off mastitis. Let your baby nurse as often as s/he is willing while you are snuggling and resting in bed.

Boost Your Immune System
Take immune system boosting supplements such as elderberry syrup, probiotics, vitamin c, and zinc. Avoid sugar, which lowers your immune response, and eat foods that are nutritious and plentiful in vitamins and minerals. Studies have found that two specific strains of probiotics are particularly helpful in fighting mastitis: L. salivarius and L. gasseri. Order on Amazon with one day shipping and start taking pronto! You can check local stores for these strains but we have found they can be difficult to source locally. 

Lactating mothers can quickly become dehydrated when feverish. Dehydration can temporarily lower milk supply. Help support your milk supply and flush out infection by staying well hydrated. In addition to drinking lots of water, ensure adequate electrolyte balance by eating foods high in electrolytes (bananas) or drinking electrolyte enhanced beverages.

Seek Medical Care
If you are not feeling significant improvement within 24 hours you need to seek medical attention. In rare situations persistent mastitis can lead to a breast abscess or bacteremia. Go to a breastfeeding medicine doctor, midwife, OBGYN, or urgent care/ER if your mastitis is not improving or is getting worse. This is true even if you are on antibiotics as sometimes mastitis is antibiotic resistant and a different prescription may be needed.

After Mastitis
After a bout of mastitis, your breast may feel bruised for several days. Milk supply is commonly lower after mastitis, but should rebuild quickly with frequent breastfeeding/pumping. We highly recommend taking a probiotic containing L. salivarius and L. gasseri following mastitis to restore healthy flora and help prevent recurrence. This is also a good time to think back to the the days leading up to when you developed mastitis to identify risk factors so you can try to avoid it in the future. Risk factors include:
  • Long spaces between feeds (feed/pump more often)
  • Oversupply*
  • Recurrent plugged ducts*
  • Cracked nipples*
  • Antibiotic use in past year (probiotics may help restore flora)
  • Run down immune system (reduce demands on your schedule to allow for more time to rest and bond with baby, take immune boosting supplements and eat a healthy diet)
  • Baby that does not drain breast efficiently*
  • Improperly fit pump flanges*
  • Tight, restrictive bra or stomach sleeping
*Meet with a lactation consultant to determine causes and solutions for these issues
Mamas in the north Charlotte and Lake Norman area, we encourage you to setup a
home visit so we can help you address these issues. If you are out of our travel area, you can setup a virtual consult with us or google "lactation consultant near me" to find local help.

Plugged Ducts

posted Jan 4, 2020, 4:57 PM by Carolyn Honea, IBCLC, CLC   [ updated Jan 30, 2020, 4:48 AM ]

What are plugged ducts?
Plugged ducts are usually a combination of congealed milk or milkfat, combined with inflammation and swelling of the surrounding tissues, causing the ducts to become swollen closed or blocked by the milk plug. When the milk making gland ("lobule" or "alveoli") does not have a way to release the milk though the duct it tends to build up, increasing the pressure and inflammation. Mothers notice specific, isolated areas of pain in their breast and often report the area feels hard or lumpy. Unlike acute mastitis, women do not experience fever or systemic symptoms with plugged ducts.
What causes plugged ducts?
Plugged ducts sometimes occur when milk is not emptied from the glands in a timely manner. This could be because of a longer than usual space between feeds or because baby did not remove as much milk as usual. Most of the time, this doesn't cause a problem, but occasionally the built up milk creates pressure, swelling and inflammation. Once swelling occurs it may squeeze the ducts and reduce the amount of space for milk to travel. During long spaces between breastfeeds (or pump sessions) the milkfat is also more likely to form clumps or plugs. Less common reasons for plugged ducts could be subacute mastitis (this is treated with specific strands of probiotics), improperly fit pump flanges, a tight bra that compresses ducts and restricts emptying if worn while pumping or breastfeeding, or, women who sleep on their stomachs leading to compression and inflammation. 

Plugged Duct Protocol:
Step 1: Reduce the swelling and inflammation so that the ducts can dilate and flow freely, allowing the build up of milk to pass.
  • Ibuprofen and turmeric (curcumin) are anti-inflammatories that can be taken according to package directions. (Consult your doctor if you have other health conditions or take medications that might be contraindicated.)
  • Lay on your back for 30 minutes with cold packs applied to the painful areas. Cold reduces swelling and inflammation. Try Lansinoh's Breast Therapy Packs which can fit in your bra or around your pump flange.
Step 2: Liquify the milkfat so that it flows freely and is less likely to form clumps
  • Take Sunflower Lecithin according to package directions. It is an emulsifier that helps fat to mix evenly into liquids and makes it less likely to clump or separate  Some women continue to take a low dose of sunflower lecithin to prevent future recurrence of plugged ducts.
  • At the beginning of the next breastfeed/pump session, apply heat for 10 minutes. Heat helps to melt/liquify the milkfat and promotes relaxation and better milk flow. Do not use heat more than 10 minutes because it can increase swelling and inflammation if overused.
Step 3: Focus on frequent and thorough breast emptying. 
  • Pump or breastfeed frequently (every 1-2 hours) until the area no longer feels swollen or hard and the pain is improving. If baby has a good latch and suck, s/he may be more efficient at clearing a plugged duct than a pump. However, if baby isn't willing to nurse often or empty fully, follow breastfeeding with pumping.
  • Massage the area or use a vibrating electric toothbrush on the area to help break up the plug. Consider using a "dangling" position while pumping or nursing where you are leaning forward or on all fours so that gravity can aid in emptying.
Repeat throughout the day until you start to feel relief. Monitor for symptoms of mastitis (fever, flu-like symptoms) and discuss with your healthcare provider if you don't feel like you are getting better. Schedule an appointment with us to help troubleshoot the cause of your plugged duct and strategies for preventing recurrence.

Oversupply: When there is too much of a good thing.

posted Aug 24, 2019, 2:28 PM by Carolyn Honea, IBCLC, CLC   [ updated Feb 20, 2020, 6:35 AM ]

An Increasing Problem
Many women worry their milk supply might be low, but few women go into breastfeeding anticipating that they might actually make too much milk. In my private practice, about 10% of consults center around the challenge of excessive milk production, sometimes referred to as hyperlactation. These women are seeking help because their babies gulp and choke at the rapid flow of milk, struggle with gas and stomach upset, may have green and frothy diapers, and the mothers may be uncomfortable with frequent engorgement, leaking, plugged ducts and mastitis. Occasionally women are predisposed to hyperlactation as a result of their breast anatomy (high milk storage capacity) or their hormone levels. However, oversupply is becoming an increasingly common phenomenon as breast pumps have flooded the market and mothers may be artificially stimulating higher milk production with excessive pumping. On social media, mommy-groups often promote the idea that women should have a freezer full of pumped breastmilk and be able to pump large quantities in one sitting. Everyone seems to forget that before 2010, most stay-at-home moms relied on a $20 hand pump for occasional relief and only working moms invested in a double electric breast pump (which was mediocre at best). Don't get me wrong - I am thrilled that insurance now makes quality breast pumps accessible to every breastfeeding mother. Women who are able to pump and store large amounts of breastmilk can be altruistic donors who are able to pass on milk to infants who wouldn't otherwise have access to breastmilk. If you have a freezer stash that will be put to good use and you and your baby aren't experiencing any negative symptoms of excess milk production, then there is no need to change anything. But for everyone else, we need to be careful that we don't lose sight of the natural laws of milk production in this culture of artificially stimulated milk production. Here is why:

Overproduction Disrupts the Distribution of Fat & Lactose
When feeding directly at breast, the average 1-9 month old will take about 2.5-5 oz of breastmilk per feed. In the context of oversupply, a woman may have 6 or more ounces in one breast alone. If it has been several hours since the previous milk removal, the milk in the breast will have had time to separate, with the fat floating to the top of the milk glands. If you have ever bought milk fresh from a dairy farm or pumped and then left the bottle to sit, you've seen the same thing happen as the cream rises to the top of the non-homogenized milk (see bottle image). This separation has sometimes been referred to as hindmilk and foremilk, but these terms led to a lot of confusion as people thought it meant the breast produced two different types of milk. It doesn't. The breast makes one consistent type of milk but after a few hours of sitting the fat naturally floats to the top of the breast and sticks to the walls of the milk glands. So, what does this have to do with oversupply? A baby breastfeeding from an overfull breast will not be able to drink all of the milk present and will first be able to drain the lower portions of milk with a higher lactose content. Baby may not have room in his tummy to drink enough of the milk for the cream top to makes its way down and out the milk ducts. In some babies, this disrupted distribution of fat and lactose may cause tummy upset.1 The fat and lactose digested together work as partners, but with lactose in high quantities separate from the fat it can irritate a sensitive tummy, rush through the digestive track and come out with bile present as a green frothy diaper.1 If your baby is showing signs of lactose overload, keep reading to learn about simple solutions to resolve this issue.
Overproduction Causes Rapid Milk Flow
Another way overproduction can cause a baby discomfort is by creating an excessively rapid flow of milk. A very full breast leads to faster milk flow as the weight of milk pushes forward to find release, much like a pent up damn opening the floodgates. If you often hear your baby gulp rapidly only to choke, sputter and cough while your milk continues to flow then you've witnessed this torrent. It can be stressful for babies to try to manage rapid milk flow and may lead to increased air swallowing and gas. 

In mild cases, adjusting into a reclined position with baby face down on the breast (see picture) will help gravity to moderate the flow of milk and give baby more control over his suck-swallow-breathe rhythms. Also, please be aware that occasionally babies with tongue-tie will struggle with milk flow even when milk production is normal. This is not caused by rapid milk flow but rather by baby's difficulty controlling the movement of milk in his mouth, leading to accidentally allowing milk into the windpipe when baby tries to take a breath between swallows.

Usually babies are great at self-regulating their intake at breast and will switch to a comfort suck once they feel full. However, very fast milk flow can cause baby to transfer a full feed in 5 minutes, which is not long enough for the hormones that signal satiety to circulate and not long enough to meet a young baby's suckling needs. Baby may even switch to a comfort suck that typically would not draw milk (one of the beauties of breastfeeding!), but due to the excess milk production and torrential flow, even a light suck may draw milk. Occasionally this leads to excessive weight gain (over 2 ounces per day) or a frustrated baby who just wants to comfort nurse and is being unintentionally "force fed." If your baby seems uncomfortable during feeds, frustrated when he tries to comfort nurse, and is gaining over 2 ounces per day this may signal oversupply.

Overproduction Increases Mother's Discomfort
Overproduction is not only unpleasant for baby, it can also be uncomfortable for mothers. Many mothers with overproduction experience frequent engorgement and feel like they have to pump often for relief. Plugged ducts and mastitis are more common because the excessive fullness and can trigger inflammation; inflammation can lead to tissue swelling; tissue swelling can cause ducts to be pinched closed, leading to a build up of trapped milk in the lobules. This is often referred to as plugged ducts and untreated can turn into mastitis. As mothers pump frequently to try to relieve the pressure, the breasts are signaled that the extra milk is being used and needed, and it reinforces the oversupply and perpetuates the problem. This vicious cycle is hard to break, but there are some solutions.

Solutions for Hyperlactation
Alternate Hot & Cold for Engorgement & Plugged Ducts
One of the most common mistakes I notice women make when treating engorgement or plugged ducts is to only use heat, such as in the form of a hot shower, soak or warm compress. If heat is used repeatedly on the breasts and not alternated with cold, it tends to increase swelling and inflammation. Since swelling and inflammation can put pressure on the ducts and compress them, over use of warm compresses can actually make the problem worse. Heat is useful for helping mothers relax and helping milkfat to soften and flow. It is best used while nursing or pumping in combination with massage. Cold packs are best used during the time in between nursing/pumping sessions. Cold helps to reduce inflammation and swelling, reducing the pressure on the ducts and helping trapped and backed up milk to escape the glands deep in the breast. If you are experiencing engorgement, use cold compress in between pumping/nursing sessions and warm compresses while pumping/breastfeeding. More time should be spent with cold packs applied to the breast than heat. Try these Lansinoh cold/hot packs for relief.

Use Breast Massage to Mix it Up
If your baby is having green diapers every day, you can easily resolve the foremilk/hindmilk separation by briefly massaging and jiggling your breasts before latching. Studies have found combining massage with pumping or breastfeeding actually increases the fat content of the breastmilk.2,3 It works by mixing the milkfat back into milk, much like shaking a bottle redistributes the fat that clinged to the edges and floated to the top.  Breast massage and jiggle before latching is called "The Milkshake Technique" and it works wonders at instantly resolving foremilk/hindmilk imbalances. If used consistently, especially anytime a woman feels full and it has been several hours since the last feed, the Milkshake Technique should quickly eliminate the green stools, gas and accompanying discomfort. There is absolutely no need to overthink the process. I do not recommend forcing baby to stay on one breast or other complicated measures that overthink the issue. Simply give those girls a little shake to mix then latch - easy peezy!

Avoid Overstimulating Production
This section applies only to women who are pumping regularly. If you or your baby are experiencing unpleasant symptoms of oversupply, the most important intervention will be to avoid artificially stimulating your production.  Ideally, pump only when your baby takes a bottle and only the same amount your baby drinks in a bottle. If you are used to pumping really high quantities (over 5oz combined), gradually shorten your pump sessions until you are only pumping to replace your baby's breastmilk intake, which is usually around 3-4oz. A little extra is fine (3oz per day into your freezer stash), but pumping high quantities will only signal your body that the milk is used and needed and to continue making that much. Make these downward adjustments to your pump sessions gradually, staying tuned in to how your body is handling the adjustment. Its okay to feel a little full during the transition, but your breasts shouldn't feel hard or inflamed. If they start to feel that way, pump or nurse enough to take the edge off and then place cold packs in your bra to reduce swelling and give soothing relief. If you have massive oversupply and are having difficulty with engorgement, then once a day, first thing in the morning, pump to fully empty your breasts so that you are starting the day with light, empty breasts. After that, follow the guidelines above to gradually shorten your pump sessions during the rest of the day.

If you are exclusively breastfeeding while coping with oversupply, your body will naturally regulate your milk supply over time. Its not unusual for women to bring in more milk than their baby needs and it takes time for the body to modify its milk production in keeping with baby's daily intake. This can take anywhere from a few weeks to a few months. Continue nursing on demand, using a reclined breastfeeding position, the Milkshake Technique described earlier, offering both breasts, and letting baby decide how much he/she wants to nurse. If your baby regularly gets full nursing from just one breast and declines the other breast when you offer it, you might consider using a silicone suction pump on the skipped breast while nursing to provide some relief. Avoid using it to collect more than 3-4oz per day as this will signal your body to continue overproducing.

Consider Herbs & Medications
If you feel you need fast relief from the symptoms of oversupply and your baby is gaining at a rate of 2oz or more per day, you can consider herbs or medications that can actually reduce milk production. Sage, in either capsule or tea form, can be consumed a few times per day to reduce production. Cabbage leaves contain a substance that can reduce production. Apply cold cabbage leaves to your breasts and change them out at each feed or when they wilt. Psuedoephedrine (behind the counter Sudafed) has been shown to reduce milk supply by 24%.4 Some women will take one dose a day of Sudafed until their milk supply regulates. With all of these options, be sure to carefully monitor for signs your milk supply is regulating and stop these measures as soon as you and your baby are feeling relief. An additional measure that won't address milk production but may help prevent plugged ducts is to take sunflower lecithin, an emulsifier that helps prevent fat from forming clumps. Ibuprofen can be used during periods of engorgement or to treat plugged ducts by reducing inflammation and thereby improving flow. Discuss any of these remedies with your doctor if you have health conditions or take medications.

Rule out Underlying Causes
In severe and persistent cases of hyperlactation, we recommend making an appointment with a breastfeeding medicine doctor or your OBGYN. They can perform bloodwork to see if a medical condition is causing extreme overproduction. In rare cases, hyperlactation can be due to hyperthyroidism, a pituitary tumor, or a side effect of a medication. Some lactation specialists speculate that systemic inflammation causes oversupply for some women, but this is not well understood yet. Think of it like your nasal passages - when they are inflamed they produce more secretions and feel swollen. Hypothetically, generalized inflammation could cause your breasts to produce more fluid and swelling. Again - not very well understood, but its food for thought! Women could try eating a Mediterranean Diet, exercise, omega 3 fatty acids, and turmeric (curcumin) if they would like to explore a natural approach to systemic inflammation, in conjunction with seeking medical evaluation.
We are here for you. If you are struggling with symptoms of oversupply, please don't hesitate to schedule a lactation consult so we can help you assess the situation and offer personalized solutions.

Resolution of Lactose Intolerance and Colic in Breastfed Babies, Health-ELearning, accessed August 2019

Low Milk Supply

posted Jan 12, 2019, 6:49 AM by Carolyn Honea, IBCLC, CLC   [ updated Jan 31, 2020, 4:31 AM ]

Low Milk Supply
Low milk supply is the most common reason women report weaning sooner than they'd hoped. (The second most common reason is pain.) There are entire books and countless medical journal articles devoted to the topic. In this article, we will scratch the surface of the topic and look at the aspects of milk production that are most relevant to the women I work with. When I was first trained in the field of lactation in 2011, we were taught that most of these cases were "perceived" low milk supply. This is a polite way to say that many women think their milk supply is low when really it may be sufficient. In my private practice, when women tell me they are worried about their milk supply it is usually a legitimate concern, and not "all in their head." If you have concerns, please read this article and then reach out for help. My passion is to help you find solutions and answers for your difficulties. First, let's define normal milk production before we dive into low milk supply.
Defining Normal
A "full" milk supply is defined as producing 25-30oz of breastmilk per 24 hours. This is a very objective way of measuring and describing how much milk a woman should be able to produce in order to support a thriving, growing baby. When our bodies work the way they are supposed to, women will reach this peak of 25-30oz within a few weeks of delivery. After the first month, a woman simply has to maintain this level of milk production until her baby is well established on solid foods and the quantity slowly decreases. Babies do not consume more breastmilk as they get older. An infant's metabolism slows over the course of the first year, causing their total milk intake to plateau. The good news is that if you can do the hard work to bring in a full milk supply during the first month, all you'll have to do is maintain it after that.

Perceptions vs Reality debate over perceived vs real low milk supply is often due to the challenge of measuring milk production when a woman is directly breastfeeding. Obviously, if you are exclusively pumping its possible to keep track and know how much you're expressing each day. For women directly breastfeeding, calculating milk production is a bit trickier. The most reliable indicator of a healthy milk supply for an exclusively breastfed baby over 2 months is to plot their growth on the World Health Organization's growth chart. A baby who is maintaining his percentile (growth curve) over time is getting enough milk to grow well and thus we know mother is producing a full milk supply. A baby who is dropping more than 5% per month off his growth curve may not be getting enough milk. Using WHO growth charts is the gold standard, objective way to determine if there is a problem with the amount of milk baby is getting. You can easily create a growth chart at home for your baby using Apple or Android apps. If your baby is less than 2 months old its harder to see trends on a growth chart, so we might use the WHO's growth standards instead, which indicate most babies should be gaining around 1 oz per day during the first two months.

Another reliable tool is to use a sensitive scale designed for lactation consultants to weigh baby before and after breastfeeding to measure intake. This is not quite as simple as it seems because babies don't take the same size feeding at each breastfeed. However, a highly trained lactation consultant can use a single feed measurement in the context of other clues (baby's feeding patterns, time since last feed, time of day, duration of feed, etc) to reliably estimate total milk production. For example, if in a lactation consult after taking a thorough history and observing a feeding I determine that baby's average intake at breast is about
3 1/2 oz and the baby usually nurses 8 times in each 24 hour period then this equals 28oz...a full milk supply. On the other hand if baby transfers 21/2 oz and mother reports baby nurses 6 times per day then we know there is at least a 10 oz shortfall. This was essentially the feeding pattern of the baby whose growth chart is pictured as poor growth pattern.

Less reliable ways to gauge milk supply are baby's diaper output (only helpful in the first week), baby's feeding patterns, and baby's temperament. These three factors can be highly variable in either direction and have to be interpreted carefully in the context of objective tools. For example, an older baby who poops infrequently, wants to nurse all the time, and is fussy is not necessarily behaving this way due to low milk supply. On the other end of the spectrum, some of the worst failure to thrive cases I have seen were babies who wet 6 diapers a day, seemed happy, and the mothers thought baby was feeding normally. The growth charts proved otherwise, as these babies were dangerously underfed. As I partnered with these families to develop a custom Care Plan to increase milk supply and baby's intake, their growth took off and these babies blossomed in every area - physically, emotionally and developmentally. Mothers often can see the difference in retrospect but not in the day to day fog of normal life. Solving these puzzles takes someone skilled in lactation and infant behavior to put the pieces together and parse out the real issues. If you are worried about milk supply, have already started supplementing or if your baby is not following his growth curve (percentiles) on the World Health Organization growth chart, schedule an appointment right away with a lactation consultant. The sooner you get help the easier it is to correct.

Producing Milk vs Transferring Milk
Let's come back to this idea that women can produce enough milk (25-30oz/day) but it doesn't necessarily guarantee baby is drinking (transferring) that much milk. Quite often, when women come to my practice due to concerns about baby's growth or their milk supply, it turns out that the mother is producing sufficient quantities of milk but baby is not transferring enough of what she is making. This is actually far more common than mother not being able to produce enough milk. The top two explanations? Infrequent feeding and tongue-tie. Let's tackle these one at a time.

Infrequent Feeding (<8 times per 24 hours)
Breastfed babies have this wonderful inborn mechanism where they naturally stop feeding when their tummy feels full, which is often around 31/2 ounces for an exclusively breastfed baby. When their tummies start to feel full, they switch to a comfort suck that doesn't draw milk. Mother may have 6oz available in her breasts, but an exclusively breastfed baby will almost never drink that much milk even if it's available. The normal range for a breastfed baby is 21/- 5 oz per feeding. This is a good thing because it helps to prevent unhealthy stomach stretching that leads to childhood obesity. (Bottle-fed babies on the other hand have a hard time regulating their intake because even a comfort suck draws milk from a bottle and perpetuates the feeding.) If you think about the fact that most breastfed babies will stop eating once they've consumed around 31/oz at each feeding, and they have to reach 25-30oz per day to grow, then it starts to become clear why its so important for breastfed babies to be offered the breast at least 8-10 times per 24 hours. Frequency of feeding is the most important driver of both milk production AND infant intake. If a baby isn't offered both breasts frequently and encouraged to keep nursing until she is full she won't take in enough total milk each day even if mother is producing enough milk overall. Over time, baby not transferring enough each day will lead to mother's supply decreasing and create true low milk supply. If your baby is not growing well and is feeding less than 8 times per 24 hours, the first solution is quite simple: offer more frequently regardless of your baby's age. In addition to responding to your baby's feeding cues, also take initiative to offer both breasts 8-12 times per 24 hours. For information on normal feeding patterns, see my article on the topic.

Tongue-tie affects about 10% of babies. It occurs when baby's lingual frenulum (see picture) is restricting the mobility and function of the tongue. Tongue-tie makes it difficult for babies to get the milk out from mother's breasts unless mother has a naturally fast and easy milk flow. Mother may be producing sufficient milk, but baby can have a hard time removing it when tongue-tie is limiting his oral-motor abilities. Like the infrequently fed baby, this eventually will lead to low milk production. Its important to treat tongue-tie once its been identified so that baby can feed efficiently and to prevent many other symptoms down the road. Click here to read my handout on tongue-tie and explore its symptoms, evaluation and treatment. In addition to tongue-tie, other less common causes of oral motor problems that can be limiting baby's transfer include low muscle tone, birth injuries and neurological issues. Until baby is breastfeeding efficiently, mother may need to pump after breastfeeding to ensure her milk supply is protected.

Causes & Solutions for True Low Milk Supply
To effectively target treatment for low milk supply, you first have to understand how milk production works what caused it to be low. Milk supply is primarily driven by the frequency of effective milk removal. Sometimes we refer to this as "supply and demand." Frequency of milk removal directly affects a mother's hormone levels and sends signals within her breasts to speed or slow the rate of milk production. The "magic number" of milk removals needed per day depends primarily on a woman's milk storage capacity. A woman's milk storage capacity is how much breastmilk her body can comfortably fit/store within her milk glands between feeds before her body starts to signal to decrease milk production. The normal range is to be able to store/fit 21/- 5 oz of breastmilk combined between both breasts. A lactation consultant can gauge this by looking at baby's feeding patterns, transfer, and mother's typical pumping output. Because each woman has such a different milk storage capacity, the frequency with which she will need to empty her breasts (breastfeeding/pumping) to maintain production will vary widely. The average range is 6-10 times per 24 hours with 8 being the most common magic number.

Infrequent Breast Emptying
As we discussed earlier, infrequent feeding (or only offering one breast each feed) explains why a mother with normal milk production could still have a baby who is not growing well. However, infrequent feeding (or pumping) is also the most common explanation for true low milk supply. Many women who start off with a high milk supply in the first week or two postpartum will develop a low supply later if they decrease how often they are breastfeeding or pumping. In my practice, the number one reason for late onset low milk supply is baby sleeping through the night. For most women, if they go longer than 5 hours at night without nursing or pumping, their body will signal to decrease milk production. Its also very difficult to hit the magic number of 8 breastfeeds/pumps per day if you are going longer than 5 hours at night without emptying your breasts. This kind of low milk supply is sneaky and insidious. It sets in gradually over a few weeks of reduced breast stimulation. If you started with a great milk supply but are now experiencing low supply, the most likely reason is you've dropped your number of milk removals each day below your magic number. Thankfully this is the easiest kind of low milk supply to fix. Simply increase milk removals again to 8-12 times per 24 hours, with no longer than a 5 hour stretch at night, and your milk supply should rebound quickly. Some herbal blends can help you rebound more quickly, but no herb can create full milk production in absence of frequent milk removals.

Pump Related Problems
For women that rely on pumping to express milk for their babies, low milk supply may be caused by issues with their pump or how they go about pumping. Sufficient milk removals each day are needed as described above. Additionally, the flanges on the pump need to be fitted correctly. Old or low quality pumps may not have sufficient motor strength to remove milk thoroughly and stimulate milk production. A new, high quality pump should be obtained with each birth of a baby if baby is going to be bottle-fed breastmilk. If you pump frequently the membranes/valves on your pump should be replaced every 2-3 months. To increase milk supply while pumping, first be sure your pump is in good condition and fit properly. Pump or breastfeed often (8-12 times per 24 hours, no longer than a 5 hour stretch at night), pump both breasts at the same time (this increases your hormone levels better than pumping one breast at a time), use breast massage and compression while pumping, and try to use visualization and relaxation techniques to improve milk flow. Pump both breasts at the same time for 20 minutes or until you have expressed the amount of milk your baby drinks in a bottle (21/- 5 oz). If you are pumping after breastfeeding to improve milk supply, pump both breasts for 10 minutes using breast massage and compression. Average output when pumping after breastfeeding is about 1 oz.

Insufficient Glandular Tissue
About 2% of mothers are thought to have insufficient glandular tissue (IGT) which means that they cannot fit/store very much milk within their breasts. One of the hallmarks of this condition is that mother's milk never seems to "come in" during the first week postpartum or is only present in very small quantities. (By the way, this can also happen to women who experienced severe hemorrhage during delivery). If a woman cannot store at least 21/2 oz combined in her breasts she will have a difficult time exclusively breastfeeding. Our knowledge about the causes of IGT is limited, but its been noticed more often in women with other endocrine (hormone) disrupting conditions such as eating disorders during adolescence, low progesterone, Polycystic Ovarian Syndrome, and insulin resistance. Lactation consultants are trained to assess for IGT markers and may be able to help you determine if IGT could be the cause of your low milk supply. Certain herbs and medications can help maximize glandular development to improve milk production, but most women with IGT will need to supplement baby in addition to breastfeeding. Metformin or domperidone are sometimes recommended for women with IGT who are trying to improve their breastmilk production. Legendairy's Liquid Gold supplement has a blend of herbs including goat's rue thought to help stimulate glandular function. If you have been diagnosed with low progesterone (common with recurrent miscarriage), taking progesterone during the first trimester of your next pregnancy may help improve glandular tissue development. Talk to your OBGYN or lactation consultant about options available to you.

Other Health Conditions
Hypothyroidism, anemia and dehydration are three of the other potential causes of true low milk supply. Dehydration sometimes occurs after gastrointestinal illness or intense exercise and needs to be corrected with electrolyte enhanced hydration (not just water). Severe anxiety and stress can indirectly affect milk supply by making it harder for a woman's milk to "let down" (flow) when breastfeeding or pumping; if milk flow is frequently impaired by a woman's stress/anxiety levels, it will eventually affect her milk supply because of the reduced milk removal. Thankfully with all of these conditions, proper treatment can help improve milk supply.  Subclinical health conditions may be alleviated by herbal blends that improve milk production.

If you are worried about your milk supply or baby's intake, get help. It can be confusing and overwhelming to try to solve it on your own. At Lake Norman Breastfeeding Solutions, we are committed to offering you respectful, compassionate care that is focused on helping you achieve your personal goals. Each woman has unique needs that deserve a custom feeding plan.

Feeding Patterns for Older Babies

posted Aug 7, 2018, 8:27 AM by Carolyn Honea, IBCLC, CLC   [ updated Feb 26, 2020, 7:06 AM ]

A Short History
Have you ever wondered why it seems like breastfeeding was more successful and came more naturally to women hundreds of years ago compared to our current generation? The answer may boil down to feeding patterns. Historian Jacqueline H. Wolf studied the history of breastfeeding in the US to learn about when breastfeeding stopped being the norm and successful breastfeeding became the exception. She says,

"This goes back to how I ended up looking at the 1880s and the 1890s as a turning point. The U.S. was rapidly urbanizing and industrializing, and that changed everything for American culture. People were starting to work in factories and they had to pay more attention to time. We see the introduction in infant-care manuals of very detailed feeding schedules. The theory was that adults were having a hard time with scheduling, but if you can adapt a baby to scheduling, they wouldn’t have that tough time. The reason that’s really interesting is that anyone who knows anything about breastfeeding works knows that the more a baby sucks, that’s what stimulates milk production. If you put a baby on a strict schedule, mothers’ milk supplies go down. So you see mothers beginning to complain that they didn’t have enough milk and it was then that the medicalization began, because doctors became involved in what seemed to be a very serious problem of lactation failure. No one connected it to the change in culture and the change in infant feeding habits."

Many of our assumptions about feeding patterns for babies originates from 150 years of living clock-bound lives and several decades of bottle-feeding as the norm. What we have come to assume is "normal" for an older baby is not necessarily normal from an evolutionary or biological perspective. Most infant schedules developed in the past 150 years were designed to get babies to accept bigger, less frequent feedings. Prior to this time most people did not even have access to clocks and followed a very flexible rhythm to their day. Not only have our cultural practices led to wide scale lactation failure, but studies have also found the obesity epidemic has roots in a child's first year of life.1 While office buildings may have replaced factories, many of the effects of the industrial revolution are here to stay. None of us are prepared to toss our clocks out the window and live bohemian freestyle lives (though its tempting!). With that in mind, let's take a look at normal feeding patterns from a biological perspective and then consider how we might incorporate this knowledge into our busy lifestyles.

Studies Documenting Average Breastmilk Intake
Studies done on healthy, full term breastfeeding babies show that babies intake peaks within the first month and plateaus at 25-30 oz per day.2, 3, 4 Surprisingly, after the first month babies do not need more milk as they get older. The first 3 months their metabolism is very high (due to rapid growth) and they need a disproportionately high amount of milk for their size.4 Later in the year their metabolism slows (as growth slows) so despite being bigger their milk intake needs are the same until solid foods start to replace milk.4 What tends to change over time is their feeding patterns - how that 25-30 oz gets divided up between feedings. Breastfed babies will only have small changes to their feeding patterns over time.4 They might space out night feedings while continuing to nurse frequently in the daytime. This is partly because mothers have limited breast storage capacity. Breast storage capacity is how much breastmilk a woman can comfortably store in her breasts between feedings before her body interprets the fullness as a signal to decrease milk production. Its determined by the number of milk glands in a mother's breast and can range widely from woman to woman.4 In my experience the average woman can maintain around 3-4 oz combined in her breasts but a few rare women can fit as much as 10 oz combined. Simple math will tell us that 28 oz (daily total) divided by 3.5 oz (average storage capacity) = about 8 feedings per day. If the average mother nurses or pumps less often than this her body will signal to decrease milk production and baby's intake will drop.

Weighing Babies Before & After Breastfeeds 
As a lactation consultant in private practice, I get to work with babies of all ages. I've weighed over a thousand babies young and old before and after feeding to calculate their intake. One of the interesting phenomenons I've observed is that even when mothers have an unusually high milk storage capacity - for example, being able to pump 8 oz at a time - their babies don't take that much directly from breast. The older babies I've weighed before and after feedings whose mothers have a great milk supply usually take 3-4 oz per feeding...only a handful of times have I seen babies take up to 5 oz. They average about 8 feedings per 24 hours with a normal range of 6-10. This same finding has been confirmed in several studies where babies of all ages were weighed before and after feeds for 24 hours.4 One of the most common reasons that women experience late-onset low milk supply or baby's growth slows is due to baby not breastfeeding often enough. People tend to assume that an older baby is taking bigger feeds which leads to offering the breast less often or letting baby sleep through the night prematurely. Its just not how nature works. If you are struggling with late onset low milk supply or a baby who is not growing well, the first thing to check is whether baby's feeding patterns are actually normal from a biological perspective. Other signs that something might be off are a baby who is up very frequently at night (possibly not eating enough in the day) or a pumping mother that can't keep up with her baby's bottle intake.

Studies Documenting Risks of Large Volume Feeds 
As the evidence accumulates for older breastfed babies sticking with 3-5oz feedings at breast, we start to realize this is the biological norm. Its not surprising then that studies have found there are health risks when babies develop feeding habits that are not biologically normal. One such study found that when babies are given bottles over 5 oz they are at higher risk of obesity.5 This is true whether it is breastmilk or formula in the bottle.6 The theory is that babies don't regulate their intake on bottles the same way they do at the breast, making it easier to stretch baby's stomach capacity.7 At the breast, only a hungry, strong suck transfers milk. On a bottle, any suck - even a light comfort suck - will cause milk to flow. As a result, bottle-fed babies tend to continue eating even after they reach satiety. This is even more so the case if caregivers are encouraging a baby to take bigger, less frequent feedings.7 We end up with a culture that expects older babies to drink 8 oz bottles, babies stomachs stretch...and then we wonder why our older children overeat.
Responsive Feeding for Modern Lifestyles 
In non-industrialized cultures, mothers often carry babies in a wrap all day and offer frequent - even hourly - breastfeeds.8,9 At night, these cultures co-sleep and have the breast available to baby throughout the night. In our fast paced, clock-bound society this often isn't possible or appealing. Instead, I recommend a balanced approach that combines responsive feeding with a biologically informed routine. This means that mothers offer the breast (or caregivers offer a bottle) at specific times in a baby's daily routine in addition to feeding responsively anytime baby "asks." Older babies might request breastfeeding by bobbing against or pushing on mother's chest or by fussing. However, I find that when mothers are offering frequently baby is very content and doesn't have much need to ask for the breast other than occasionally for comfort. It gives you the chance to confidently plan activities in your day's routine and gives baby prediciability that often leads to improved sleep

Below is a daily schedule that includes mother-led feedings when baby wakes up in the morning, before and after naps, and at bedtime. Most babies also wake once or twice a night to nurse until they are skilled at eating from all food groups. (Early night weaning leads to low milk supply unless mother pumps at night.) If you are looking for structure to your day, my suggestion is to build a routine that centers around nursing upon waking, before and after naps, and at bedtime. As an added benefit, breastfeeding before naps helps baby sleep better thanks to the sleep inducing hormones in breastmilk such as melatonin. This feeding routine also keeps baby from waking up early due to hunger. (If you need help troubleshooting sleep issues, see my article series on infant sleep.) The exact times are less important and can be adjusted based on you and your baby's needs. 

If your baby is bottle-fed, you can still use the schedule above. Or you can build your own schedule using one of the two sample feeding patterns below.  The guidelines below are typically more helpful for bottle-fed babies. You'll notice that the quantity of breastmilk decreases with age as solid foods play an increasing role in baby's diet.  Keep in mind if you are breastfeeding its not possible to nurse "too often" or "too much." Babies won't overfeed at the breast. All you are doing is offering and responding, not forcing. So don't be afraid to nurse often. For more tips on healthy bottlefeeding, see Bottlefeeding the Breastfed Baby.

The Best of Both Worlds
Combining responsive feeding (nursing anytime your baby wants) with offering scheduled feedings (a routine based on biological norms) is possible and may be the solution modern families need to make breastfeeding successful in the midst of a structured lifestyle. If you need help figuring out the best routine for your milk production, your lifestyle, or your baby's needs please feel free to make an appointment. I am happy to help!

Breast milk volume and composition during late lactationJ Pediatr Gastroenterol Nutr., 1984
Why African Babies Don't Cry, accessed 08/2018

Preparing for a Lactation Consult

posted Jul 9, 2018, 1:29 PM by Carolyn Honea, IBCLC, CLC   [ updated Feb 29, 2020, 5:26 AM ]

Once you've successfully scheduled a lactation consult, you might be wondering if there is anything you need to do to be ready for your appointment. Here are some pointers...

Fill out the Lactation Network form:
Fill Out Form
- If you have Blue Cross Blue Shield, Anthem or Cigna you may be able to have the cost of your lactation consults covered 100% by insurance.
- Fill out this form with our billing partner, Lactation Network, to confirm your eligibility. List Lake Norman Breastfeeding Solutions as the referring Lactation Consultant:
- If you are approved, we will upgrade your appointment length to 90 minutes (vs 60) and bill directly to insurance at no out of pocket cost to you.

Collect your thoughts leading up to the appointment:
-If you booked your appointment online, you've already filled out our new client form. If we booked it for you, please be sure to check your email and use the emailed link to edit the forms.
- Jot down a couple of your questions/concerns that you want to remember to discuss
- Be prepared to describe your baby's feeding patterns (if you aren't sure, count how many times your baby typically feeds for the next 24 hours)
- Be prepared to describe any other details such as your pumping routine, bottlefeeding routine, preexisting health conditions, and your baby's weight history

Getting baby ready:
- If possible, time it so that baby is hungry and ready to feed during your appointment. You might try offering a feed to baby 2 hours prior to consult even if it is early for baby's feeding, just to help baby make it to the appointment.
- If you end up needing to feed baby shortly before the appointment, keep it short and feed just enough to take the edge off. Its important for us to be able to assess as full of a feeding as possible.
- For home visits, have baby undressed and wearing a clean diaper. One of the first things we do at every appointment is weigh baby wearing just a dry diaper.

Getting yourself ready:
- Wear something with easy access to the breast. The less fabric and restrictive clothing in the way the better. If you are comfortable with skin to skin during the consult, skip the bra and just wear a bathrobe or kimono on top.
- If you have long hair, pull it back so that we can get an easy view of baby's latch.
- You do not need to put on make-up or look your best. We are used to visiting with postpartum moms in yoga pants worn since the day before, milk soaked camisoles, and dishelved hair! Trust us, your inner beauty has never shined brighter!

Getting your home ready:
- The only exception to this is if you would like help working your breast pump. Have all the parts collected in one spot and the pump in the room.
- We are used to messy homes - a messy home tells us you are more focused on caring for baby and getting your rest (hopefully), which is exactly what we recommend!
- We like to be in whatever room you would like the most help getting comfortable. This might be in your own bed, the nursery, or the family room. We can even rotate between rooms so that you can find comfortable setups on different furniture (bed, rocker, sofa).

ONE MORE THING! If your partner/spouse is on paternity leave we would love for them to be present for the consult as well. See you soon!

Top 5 Pumping Tips

posted Mar 1, 2018, 6:10 PM by Carolyn Honea, IBCLC, CLC   [ updated Feb 4, 2020, 2:11 PM ]

Use a Pumping Bra & Multitask

Perhaps the most important tip for pumping is to have a setup that allows you to do other things you enjoy (like snuggling your baby) or need to do (like commuting) while you pump. In order for this to happen, you absolutely need a hands free bra. Otherwise, you'll find yourself skipping or shortening pump sessions due to the inconvenience of having to be tied to a machine and holding your flanges for extended periods. If possible, purchase the Spectra S1 or S9 pump so that you don't have to be connected to an outlet. After its charged, the Spectra S1 will run for three hours on its built-in battery. If you have the Spectra S2, you can buy a car adapter plug for just $10. When you have a portable pump, your options for pumping multiply - you can pump while walking around the house, in the car, or in bed! Having a Brauxiliary Band or pumping bra will also enable you to pump hands-free and hold baby, work, or drive at the same time. Check out this video on how to pump hands-free while driving:

Holding your baby while pumping also helps you multitask and pump more successfully. You can snuggle your newborn on your chest in between the pump flanges or position them on your lap for a bottle while pumping. Check out the tips in this video:

Simplify Your Cleaning Routine

If you pump multiple times a day, instead of washing your pump parts every time you use them, store them in the fridge in between pump sessions. You can leave your pump parts out for up to 6 hours at room temperature or for the day in your refrigerator. Simply unplug the tubing from the back of your flange and place the bottle/flange combo into the refrigerator in between pump sessions. You can discreetly hide it in a lunch bag if you are using a community fridge at work. If you pump exclusively, consider purchasing a portable mini-fridge to keep in your car, workplace or bedroom. If you place your pump parts in the fridge between pump sessions there is no need to wipe or rinse - in fact, the breastmilk that coats the flange and bottle will actually help it to stay fresh thanks to breastmilk's germ fighting properties. Washing your hands before pumping also helps keep it a germ-free environment. Once a day, disassemble the pump accessories and wash them thoroughly. You can hand wash or place the parts in the dishwasher's basket. Now you only have to clean once a day!

Maximize Output with Breast Compressions
Hands-free pumping is awesome for moms that are multi-tasking or on the go. But if you are trying to maximize your pumping output, nothing works better than using breast massage and compressions while pumping. Place your hand around your breast as shown in the picture and massage the deep, lumpy layers of your breasts (the milk ducts) while pumping. You'll notice a significant increase in the amount of milk you pump over time and also a thicker fat layer in your milk. Its thought that massage helps shake loose milkfat that sticks to the walls of the milk ducts resulting in higher fat content in the pumped milk. Check out this amazing video by Stanford Medicine on how to combine hand expression with pumping for greater breastmilk output and higher fat content: Maximizing Milk Production 

Customize Your Pump's Settings & Fit

Experiment with your pump's settings to find the perfect speed and vacuum setting for your body. Spectra pumps allow you to independently set your pump's cycle speed and vacuum strength, so you can find just the right setting for your body. In general, studies have found that using stronger vacuum settings results in higher milk production - though you should never turn up your pump so high that it causes pain. The speed setting is also very individual, but many women find that starting with a light, fast cycle helps to get their milk flow started and then after let down occurs they switch to a slower, stronger cycle. You can easily toggle back and forth between let down mode and expression mode by pushing Spectra's wavy button. On Medela pumps, the vacuum and cycle speed are not independently adjusted, so try starting with your pump on a lower setting and then turn the dial up gradually once your milk starts flowing. Its important to use the right flange size for your nipple size. There should be 1-2mm of air space around your nipple inside the flange. Your areola should not be pulling into the tunnel. Most women are using too big of a flange, resulting in less milk extraction and greater discomfort.

Know Your Magic Number

Your breasts are signaled to maintain milk production by frequent milk removal. On the other hand, your breasts send a signal to decrease milk production if the milk is allowed to build up in the breast for several hours without being emptied. Your body thinks sitting milk is wasted milk and plans to make less in the future. Whereas frequently emptied breasts (via pumping or breastfeeding) signal your body to stay busy producing milk. Most women need to remove the milk from their breasts about 8 times a day, or every 3 hours, in order to maintain milk production. Keep in mind this number includes all milk removals whether via breastfeeding or pumping. For mothers trying to increase milk production, their breasts may need to be emptied 10 times a day. However, some lucky women have what's called high milk storage capacity, which means they have a higher than average number of milk ducts and therefore can fit a lot of milk in their breasts before their body signals to decrease supply.

Women with high milk storage capacity can easily pump over 5 oz at a time (combined) without feeling any engorgement between pump sessions. They can get by with less milk removals, such as 6 times per day, and still be able to maintain full milk production. The number of times your breasts need to be emptied per day (breastfeeding or pumping) to maintain milk production has been called "your magic number." Be careful to not drop below your magic number or else milk production will gradually decrease over time. Full milk production is considered 25-30 oz per day, and divided between 8 sessions (the "magic number" for most people) that would equal about 3.5 oz per session. If you can easily pump more than 3.5oz each pump session, you can try to drop down to 6-7 sessions per day but be watchful for signs that your body is signaling to decrease production. If you notice your output gradually declining over time, add one or two breastfeeding/pump sessions back into your routine. Also note that most women need to pump for about 20 minutes, but you can shorten this time if your milk flows quickly and you have expressed the amount of milk your baby needs.
Schedule a lactation consult in-home, at our office in Davidson, NC, or virtually for customized advice on pumping and bottlefeeding.

Breastfeeding Smaller Newborns

posted Oct 6, 2017, 1:22 PM by Carolyn Honea, IBCLC, CLC   [ updated Feb 28, 2020, 1:56 PM ]

Breastfeeding Smaller Newborns
Newborns born on the smaller side (under 8 pounds) are some of the snuggliest, sweetest babies out there. However, they present unique challenges when it comes to breastfeeding and require a proactive approach.1,2 In this post, we discuss 3 milk supply related challenges of breastfeeding small (under 8 pounds) or late preterm/early term babies (35-39 weeks) and the strategies that lead to breastfeeding success.

Challenge #1: Sleeping Instead of Eating
Early term babies and newborns under 8 pounds tend to LOVE sleeping even more than they love eating. While this might sound like a good thing, it often causes these babies to sleep through their hunger and therefore not take in enough breastmilk. Letting your small newborn skip feedings because she is sleeping will signal your body to slow down milk production.2 Missed feedings may also slow her growth and perpetuate the sleepy/poor feeding pattern.2 Thankfully, awareness goes a long way in heading off this problem.
Solution: Wake baby every 2-3 hours to nurse.
Until baby is showing consistent feedings cues and growing well, wake her up often enough to equal 8-12 feedings per 24 hours.1 Frequent feeding is crucial to establishing a good milk supply and helping baby grow. In fact, I consider it the #1 key to success. Nurse your baby anytime she shows feeding cues but also wake her to nurse as needed to achieve 8-12 feedings per 24 hours. If baby is sound asleep around the 2 hour mark (since start of last feed), try getting her less comfy by placing her on her back next to you on a flat surface instead of being swaddled or snuggled. Gently move baby's arms and legs and talk to him/her. This allows baby to enter a light sleep stage and start to notice he/she is hungry and hopefully begin to show feeding cues. If baby still isn't beginning to rouse after about 15 minutes, undress her and change her diaper.

Challenge #2: Sleeping While Eating
Because of their love of sleep, little babies are often great imposters at the breast. They latch on, take a few comforting swallows of breastmilk, and then relax into a deep sleep with only gentle, fluttering sucks. 30 minutes later, they are still attached to the breast but have taken in very little breastmilk. After all, the breast is their favorite place to snuggle up for a good nap. So what's the problem? With very small or late preterm babies, they will often fall asleep at the breast before they've filled their tummies. The lure to sleep is just too great! Many a mother has been fooled by this seemingly normal feeding behavior into assuming baby is nursing well until a checkup at the pediatrician shows otherwise.
Solution: Encourage active sucking and swallowing.
Taking an active approach to ensure baby fills her tummy and empties your breasts is important. Pay attention to when baby's sucks change from strong and regular to weak and slow. When this happens you will probably also notice that swallowing is no longer heard and her eyes are closed. If this transition from "active sucking" to passive suckling happens after just a few brief minutes, then try to stimulate baby to suck more vigorously. Gently stroke her skin, tickle her feet and talk to her. Use breast massage and compression to speed milk flow by intermittently pressing on and then releasing the lumpy areas of your breast.1 Once you feel like baby has filled her tummy and emptied your breasts, you can let her sleep at the breast as long as you want. 

Challenge #3: Building Milk Supply
Babies born over 7 pounds typically clusterfeed the first week to build mother's milk supply until it reaches 25-30 ounces per day and then they maintain this amount the rest of the year (surprising, isn't it?!).3 This increase doesn't happen nearly as quickly for babies born under 7 pounds. For example, a baby who is 5 pounds at discharge from the hospital will probably take a month to get over 7 pounds and up to mature intake (25-30oz). During the first month, the smaller baby will likely only be taking in about 20oz of breastmilk per day (beginning around day 7 of life). The dilemma is that it becomes harder to increase milk supply after the first few weeks. Our bodies are programmed to reach peak production quite quickly and after that to maintain it. Many mothers of small/preterm babies struggle to build their milk supply in the second month if they did not reach peak production in the first month.
Solution: Pump Twice a Day
If your baby is currently under 7 pounds and exclusively breastfeeding, it may be wise to pump twice a day (or more if your lactation consultant advises) as a buffer for your milk supply.2 This will allow your body to quickly and easily reach full milk production during the first month so that baby can naturally grow into it later. Try a routine of pumping once in the A.M. and once in the P.M.. Pump both breasts immediately after breastfeeding but only for about 10 minutes. This way you are only taking the leftover milk that baby did not drink and not taking milk from his next feeding. Use hands on massage and compression to get out every last drop as shown in the link here. The quantity you will be able to pump each session could be as little as 1 oz (quite common) or possibly as much as 4 oz (less common). If your baby is growing well right now you can freeze this extra milk for future use. If baby is gaining less than one ounce per day, this pumped milk should be supplemented back to baby.1,2 If you follow this routine until your baby is 7 or 8 pounds, you will have a comfortable stash of breastmilk saved up in your freezer. Better yet, you won't be wrestling with low milk supply when your baby is ready to take in larger feedings at the breast.

1 Breastfeeding the Late Preterm and Early Term Baby, Academy of Breastfeeding Medicine Protocol # 10

1-10 of 35