Low Milk Supply

posted Jan 12, 2019, 6:49 AM by Carolyn Honea, IBCLC, CLC   [ updated Jan 21, 2019, 11:38 AM ]

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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 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 Jun 12, 2019, 1:35 PM ]

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 Sep 10, 2019, 10:15 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...

Call Aetna for pre-approval:
- If you have Aetna health insurance, call the phone number on your insurance card and request pre-approval for lactation counseling services. You may be eligible for up to 6 lactation consults covered at 100%. 
- Due to the lack of in-network providers in the area, you can request "network insufficiency" coverage which, if approved, means they will cover the consults as if they were in-network
- If they ask, you can tell them we use CPT code 99404 and Dx code Z39.1.
- You will pay for the lactation consult yourself (cash, credit or check) and then submit the receipt to Aetna for Aetna to reimburse you.
- For other health insurance plans, we recommend downloading the Better app which makes filing out-of-network insurance claims a breeze. Also see our tips here for filing a claim with your insurance provider.

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

Having baby ready to go:
- 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).

See you soon!

Top 5 Pumping Tips

posted Mar 1, 2018, 6:10 PM by Carolyn Honea, IBCLC, CLC   [ updated Sep 10, 2019, 11:52 AM ]

Pump Hands-Free on the Go
If possible, purchase the Spectra S1 pump or another portable 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. Check out this video on how to pump hands-free with a Bruaxiliary Band while driving:

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.

Breastfeeding Smaller Newborns

posted Oct 6, 2017, 1:22 PM by Carolyn Honea, IBCLC, CLC   [ updated Aug 7, 2018, 12:45 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 very difficult to wake, changing her diaper on a flat, hard surface (like a tabletop) is sure to wake her up.

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 hereThe 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

111 Reasons to Breastfeed

posted Aug 1, 2017, 10:20 AM by Carolyn Honea, IBCLC, CLC   [ updated Oct 6, 2017, 1:32 PM ]

111 Reasons to Breastfeed
Guest post by Jenny Silverstone

Being a mom is expensive. All your disposable income seems to go to baby gear and doctor’s visits, and sometimes, even when your paychecks are gone, you still have a long list of essentials you need to get.

Feeding your baby is one area where you can cut costs dramatically. Instead of spending $100 a month or more on formula, you can breastfeed, which doesn’t have to cost a thing. But saving money is just one of the many benefits of breastfeeding.

To help moms make an informed decision about which method of feeding they’ll choose, Mom Loves Best has created a list of 111 reasons why breastfeeding is the superior feeding choice.

In addition to being cheaper, breast milk provides the perfect nutrition for a growing baby -- she doesn’t need anything else. So while you’re saving money, you can rest easy knowing your baby is getting everything she needs to grow up healthy and strong.

The health benefits of breastfeeding are amazing, with breastfeeding reducing both you and your baby’s risk of getting cancer. Using the milk your body produces can also help decrease autoimmune risk, contribute to heart health and foster a closer relationship between you and your baby.

Although it's not only mommy and baby that get all the benefits. Everyone in our society has the potential to gain as a result of lower medical expenses, less air and landfill pollution, increased work productivity and fewer sick days taken by breastfeeding mothers and their children. Not to mention the fact that UNICEF estimates a whopping 1,300,000 lives could be saved each year if more women breastfed their babies.

It's no wonder that this year's World Breastfeeding Week (August 1-7) is centered around "working together for the common good," because it's clear to see that a woman’s decision to breastfeed is a decision that benefits us all.

About the Author
Jenny Silverstone is the mother of two, a breastfeeding advocate and a coffee addict. You can find her writing about how she overcame her struggles with breastfeeding on her blog, Mom Loves Best.

Spectra vs Medela Pumps

posted Jul 10, 2017, 11:37 AM by Carolyn Honea, IBCLC, CLC   [ updated Mar 28, 2018, 9:51 AM ]

Why I Became a Spectra Retailer

As a lactation consultant, I talk to moms about their pumping experiences and hear the pros and cons 
they encounter with various brands of breast pumps. In the past two years a new brand, Spectra, began drawing my attention as many moms started to report that their Spectra pumps were quieter and gentler than their Medela pumps. At the same time, reports began surfacing on the mold issues with used Medela pumps (see right pic of the inside of a Medela). Moms were also encountering a loss of suction power in their Medela pumps especially when they were used second hand or for more than one year. All this led me to start recommending Spectra pumps over Medela. Spectra's closed system prevents milk from entering the tubes and infiltrating the motor, which can lead to mold growth. Its hospital-strength motor comes with a two year warranty and is less likely to putter out when a mom is working full time and pumping. Its quiet rhythm sounds more like a soft sound machine than a whirling factory machine. And its gentle vacuum makes for a more comfortable pumping experience. The Spectra S1 also boasts a built in rechargeable battery that makes pumping on the go super convenient.

Spectra S2
Thanks to the Affordable Care Act, most women are able to get a free breast pump from their health insurance. Most insurance agencies allow women to choose from a list of covered pumps that typically include a Spectra S2 (see list below). The Spectra S2 is a great option for most women! However, some women who do not have traditional health insurance or who want to upgrade to a Spectra S1 (for the rechargeable built-in battery) may want to pay out of pocket for breast pumps and accessories. Because of this, I decided to become a Spectra retailer to make their pumps and accessories available as part of the comprehensive services offered by Lake Norman Breastfeeding Solutions. If you would like help choosing from the Spectra products I carry, please schedule a Free Product Consult at your convenience. I keep my prices competitive with Amazon and below retail value, but the real savings is that you can avoid sales tax and use your Health Savings Account when purchasing pumps and accessories from Lake Norman Breastfeeding Solutions.

Sleep and the Breastfed Baby, 6-12 months

posted Feb 15, 2017, 7:23 AM by Carolyn Honea, IBCLC, CLC   [ updated Jun 12, 2019, 2:11 PM ]

Sleep & the Breastfed Baby

6-12 Months

Studies show that the majority of babies are still waking one or two times a night at 6-12 months of age regardless of whether they are breastfed or formula fed.1 In my practice as a lactation consultant working with nursing babies young and old, many start sleeping through the night around 9 months. They may continue to occasionally wake and need to be settled after a bad dream or other sleep disturbance, but are not necessarily nursing at night. Although night nursing is biologically normal, its not unreasonable to expect or encourage a 9+ month old to night wean. Milk supply always decreases when baby sleeps through the night (unless mom pumps at night) but after 9 months most babies are able to make up the gap in decreasing milk supply with an increase in solid foods. This is a natural part of gradual weaning. Just keep in mind that based on the studies available, night weaning does not always lead to sleeping through the night.1

My older baby is up several times a night, how can I reduce nightfeedings?

Ensure ample daytime breastfeeds. Between 6-8 months, most babies need to maintain the same amount of breastmilk in their diet and probably are not ready to drop breastmilk feedings yet. Most breastfed babies cannot simply take bigger less frequent feedings, since most women only produce an average of 3.5 oz per breastfeeding.2 Breastfed babies need the same feeding frequency to maintain their overall milk intake (around 27oz per 24 hours3) until they are proficient at eating nutrient dense solid foods. Decreasing breastfeeding frequency prematurely leads to a hungry baby waking up at night. If your baby is night nursing often, take a look at his daytime feeding patterns. If his daytime milk feeds are only around 5-6 times per day, this may explain why he still needs 2-3 night feeds to get to the typical need of 8 breastfeeds per 24 hours. Eliminating night feedings means more of those feedings must be pushed into daytime hours, not eliminated altogether. Once baby is eating a significant amount of solid foods he may be able to decrease his overall milk intake, and drop some breastfeedings out of his day/night.4 Of course, every baby is different and some babies are able to thrive with bigger less frequent feedings, but those babies will be growing on track (maintaining percentiles on the WHO chart for weight) and sleeping well. If your baby was growing well and sleeping well you probably wouldn't be reading this article! Here are some averages for breastmilk intake:

Learn more
Please note this chart is based on averages!3,4 Every mother/baby pair has a unique "magic number" mostly determined by mom's milk storage capacity and influenced by baby's solid food intake. There is a lot of room for diversity as long as baby is growing on track. For more information see The Magic Number & Long-term Milk Production and Feeding Patterns for Older Babies. Lactation Consultants can determine your baby's per feed intake by weighing baby on a very sensitive scale before/after breastfeeding.

Ensure opportunities for nutrient dense solid foods.
 Before 6 months, studies have not found any benefit to a baby's sleep when solid foods are introduced.5 After 6 months, increasing the quantity of solid food intake does seem to help babies night wean although they may still wake.1 Slim babies will especially benefit from nutrient dense solid foods offered right after nursing. Avocado, salmon, and scrambled eggs are all foods high in healthy fats and protein to help fill a baby's tummy. Baby should be allowed to set the pace for solid food intake without pressure from caregivers, as pressured spoon feeding can lead to childhood obesity.4 However, sometimes babies who are not given enough opportunity to eat solid foods will be waking at night hungry. Have older babies sit with the family at every meal so they can learn and gain interest by watching family members eat. Offer soft table foods from all the food groups (proteins, fats, grains, produce, etc). For more information, see my article on Baby-led Solids or attend a Baby-led Solids & Weaning Class.

Have a consistent sleep routine. Most 6-12 month olds are taking two naps per day. Having a consistent wake time, nap times, and bedtime can all help baby's night sleep be more predictable. The No Cry Sleep Solution offers gentle suggestions for how to create an age appropriate sleep routine. Baby should nap in a dim room with white noise - especially if there are noisy siblings in the house. Try to nurse baby before naps until baby is drowsy but not sound asleep. Falling asleep on his own may help him be able to resettle at night. Read more sleep tips from Babycenter.

Try gentle sleep training techniques, if desired.
If your baby is nursing more than once or twice a night (ages 6-8 months) or still night-nursing after 9 months and you've tried the above 3 steps, then some very gentle sleep training may be an option for your family. Never sleep train your baby out of pressure from friends or just because its considered "normal" in our culture for a baby to sleep through the night. Only you can make the decision if it is right for your family. Some gentle sleep training approaches are 1) Reducing the duration of night feeds - gently end the feeding after 5 minutes. 2) Move baby into a separate room. 3) Ask dad to rock baby, offer pacifier, or pat baby's back. 4) Allow baby the opportunity to settle by waiting up to 10 minutes before going in the room. These approaches work best if tried in order listed and each step is given at least one week of consistent effort before moving to the next step.

Remember, this too shall pass! Although the season of tending to an infant's nighttime needs feels long and exhausting, it doesn't last forever and it is part of the developmental process of building a foundation of love and trust with your baby. Children eventually learn to sleep through the night - except for the occasional nightmare, bedwetting, and midnight tummy bug. Although it may be hard to imagine now, the time will come that you may look back fondly at those late night snuggles and wish you could have those precious moments back. 

Breast milk volume and composition during late lactationJ Pediatr Gastroenterol Nutr., 1984
Infant sleep and bedtime cereal J Dis Child, 1989
Baby knows best? The impact of weaning style..., Nutrition & Metabolism, 2012

Infant Growth: What EVERY Mother Needs to Know

posted Jan 19, 2017, 10:36 AM by Carolyn Honea, IBCLC, CLC   [ updated Jun 12, 2019, 1:59 PM ]

A universal concern for new parents is whether their baby is getting the right amount of breastmilk/formula (henceforth referred to as "milk"). Because of conflicting information given to parents regarding infant feeding patterns and milk intake, parents may be relying on inaccurate or even dangerous information regarding their baby's feeding needs. On one extreme this can lead to overfeeding and set a child up for life long obesity, and on the other extreme it can lead to underfeeding and malnutrition. After seeing many parents caught off guard by their infants feeding problems, I've come to believe that it is vitally important for all parents to understand normal infant growth since this is the most accurate way to gauge if an infant is being adequately fed. My experience was recently validated by a study showing that when mothers are taught how to follow their baby's growth their breastfeeding practices improved, baby's weight improved, and they were more likely to breastfeed successfully.1

When a typical child is growing in a healthy environment and fed an appropriate amount of milk, they will follow a predictable pattern of growth.2 This does not mean that every baby will be the same size - far from it! As we all know, genetics are a major determiner of whether a person is of small or large stature. However, when researchers have followed the growth of thousands of children from all genetic backgrounds in optimal environments and they have found they all have a similar growth pattern.2 These patterns are what make up the data found in the WHO Growth Chart and the percentiles your pediatrician may inform you of at your child's well checks. For example, naturally smaller babies may hover around the 20th%, not varying dramatically up or down over the course of the year. Whereas a naturally bigger baby may hover around the 80th% throughout the first year. Both are considered healthy growth patterns since they maintained their percentile. Also note that growth charts work best after the first month, since birth weight may be influenced more by pregnancy related factors. (During the first month, a weight gain of 1 oz or more per day is normal, beginning on day 4 of life.*) Small, gradual shifts on growth charts are usually okay. A red flag for a feeding problem would be a baby whose percentiles are rapidly increasing or decreasing. If you notice this, immediately make an appointment with a lactation consultant or pediatrician to discuss your concerns. 

Identify if Your Baby Could Be Underfed
While medical problems can cause poor growth patterns, if an otherwise healthy baby is dramatically swinging up or down in their weight percentiles it may be a clue that there is a feeding problem. Breastfeeding problems especially are best treated as soon as possible. If parents are tuned in to their baby's growth they can quickly seek out the support of a lactation consultant before a problem has gone on too long. The graph to the right is an example of baby whose growth should have raised red flags long before she came to see me at 7 months. The problem could have been identified much sooner, when her growth dropped off between 2 and 4 months. Notice how the red line representing her weight trends upwards in a nice curve from birth 2 months, but then begins to flatline, and her weight percentiles plunged from 97% to 1%. This baby was being seriously underfed, quite to the surprise of her parents who thought she was happy and thriving. If parents are equipped to monitor their baby's growth they can catch a problem early and get help from an expert on what changes need to be made. In this case, baby was not nursing nearly often enough to support a healthy milk supply.

Identify if Your Baby Could Be Overfed
In general, breastfed babies are really good at regulating their intake at the breast. Studies have 
found that breastfed babies feed slower than bottlefed babies and this helps them to sense fullness and switch to a non-nutrive suck that does not draw milk.3 One exception to this is when mother has oversupply and a very fast let down - the milk can flow so fast and furious that baby will rapidly swallow just to keep up. Bottle-fed babies, whether taking in breastmilk or formula, are prone to overfeeding.4 They are unable to comfort suck on a bottle like infants at the breast without drawing additional milk, so they may overfeed simply to satisfy their sucking needs. Because of the fast and effortless flow of bottles, they may drink the milk too quickly before they have a chance to register fullness. Caregivers also tend to encourage a baby to finish a bottle instead of looking for subtle cues the baby is full. Widespread false information exists on how much milk older babies should be taking in a bottle, leading to vast overfeeding of older babies. For this reason, its not a bad idea for parents to be on the look out for excessively rapid growth as well, since this may be a sign of overfeeding.4 Notice in the chart on the right how baby was small at birth (9%) but had a nice upward curve of the growth line to 2 months (19%) and then a rapid uptick in growth occurred launching the baby up to 40% at 4 months, 77% at 5 months, and 90% at 7 months. In this case, when mom went back to work the caregiver began overfeeding the baby at daycare. Instead of continuing small frequent feedings like breastfed babies maintain (example: 8 x 3.5 oz feedings per day) the caregiver was giving large 6-8 oz bottles. Once we caught the problem at 7 months, we were able to teach the caregiver paced bottlefeeding methods and gradually adopt a more healthy feeding pattern.

Boost Confidence In Your Milk Supply
Most new moms worry about their milk supply. It can be unsettling not being able to see and measure how much milk your baby is drinking at breast. There are several observational ways to watch for signs of a good milk supply (topic for a future blog post!), but the Gold Standard-No Question test of a good milk supply is to see your baby's growth steadily follow a curve on the growth chart and maintain approximately the same percentiles. Keeping an eye on your baby's weight percentiles is actually much easier than keeping track of how many ounces they are supposed to be gaining, since the rate of growth is constantly changing. For example, a 3 week old is expected to gain at least half a pound per week but a 5 month old is only expect to gain half pound every two weeks. Instead having to know the ever-changing rate of expected growth, simply monitor your baby's weight percentiles. You can be 100% confident that you a have a full, healthy milk supply and that your baby is feeding well if you see baby's growth line follow a steady curve and roughly maintain his percentiles (gradual shifts are usually okay, just not sudden or dramatic shifts). Notice how the baby on the right has a steady growth line that roughly follows a curve on the chart, and her percentiles don't vary widely. This baby is growing and thriving and mom can be confident in her milk supply.

Charting is Easy!
You can easily download a free app to chart your baby's growth. All you'll have to do is plug in your baby's weight at each checkup and the app will create the line and percentiles. Its very important to make sure you are using the World Health Organization (WHO) chart, not the CDC chart. The WHO chart was made based on data from thousands of healthy babies from around the world who were living and fed in healthy environment.5 As a result, the chart shows what normal healthy growth should look like. This is different than the CDC chart which was made with babies that were not growing in healthy conditions - so the percentiles really aren't helpful for identifying ideal growth.4 You learn more about the differences in charts here.

Get Help If Concerns Arise
If you have concerns about your baby's growth, its best to seek out the help of a feeding expert instead of making changes yourself. Sometimes its hard for parents to discern if a fluctuation is considered normal or alarming. A lactation specialist is trained in both breastfeeding and bottlefeeding, and can help you identify if your baby has normal feeding patterns, the condition of your milk supply, and what if anything needs to be changed. Your lactation consultant will also involve your baby's pediatrician to make sure that no other health conditions are contributing to growth problems.

* Weight Velocity, WHO, accessed 7/11/17 

Selecting Milk for Your Toddler

posted Nov 1, 2016, 1:36 PM by Carolyn Honea, IBCLC, CLC   [ updated Mar 28, 2018, 10:01 AM ]

When it comes to selecting the right milk for your toddler, there have never been more options. The grocery store's milk aisle is full of choices - cow's milk at all fat levels (whole, 2%...) and with options for organic, lactose-free, and grass-fed; goat's milk; plant-based milks made from coconuts, cashews, soy, rice, or almonds; and probably more I'm leaving out. Then there is the milk you won't find in the grocery store but was the norm for thousands of years - human breastmilk - which may or may not be available to you depending on whether you are still nursing. It can be overwhelming and confusing trying to figure out which milk is best for your toddler. Your pediatrician tells you one thing, the American Academy of Pediatrics says something else, and other mommies in your online group say something completely different. Here are a few facts to help you sort through the options and select the best fit for your little one:

The Benchmark - Breastmilk
Mammals - be they human, bovine, chimp or otherwise - continue to nurse their young until their offspring's immune system and brain are well developed. Historic, anthropological, and scientific evidence all point to breastfeeding as the human norm for children until 2-7 years of age.1  For this reason, the World Health Organization recommends breastfeeding for at least two years, and beyond as long as mother and baby desire. In the United States, only 34% of babies are still breastfeeding at 12 months,2 so that leaves 66% of infants who will need an alternative milk. But before we consider the nonhuman milks available, it helps to start with some knowledge of the components of human breastmilk so we can know what to look for in a suitable alternative.

Human breastmilk changes as a baby grows to best complement his/her needs. The breastmilk produced for a toddler has become concentrated, containing a higher amount of fat and calories compared to breastmilk produced for an infant.This means a toddler does not have to consume the same quantity of breastmilk as he did when he was younger to still get the same nutrients.4 Here are a few of the superstar components of breastmilk that are especially important for toddler health but sometimes overlooked:

Fat & Cholesterol Breastmilk is full of "healthy fats" and cholesterol that are crucial for brain building.You may be used to thinking of these nutrients as something to limit, but for young children fat and cholesterol are literally the building blocks of the brain. Without adequate fat (50% of caloric intake) and cholesterol, the brain "starves" and is unable to grow to its full potential.5 With 80% of the brain's growth occurring in the first three years, this is something to be taken seriously!

Protein - Breastmilk contains high amounts of easy-to-digest protein. According to, "Protein is a major component of your muscles, organs and skin. The protein in your diet also helps your body repair cells and make new cells. This is especially important for children, because children are constantly going through periods of growth and development. Protein also allows for proper wound healing and helps the body maintain fluid and acid-base balance."

Calcium - Breastmilk contains easily absorbed calcium. According to, "Younger kids and babies who don't get enough calcium and vitamin D (which aids in calcium absorption) are at increased risk for rickets. Rickets is a bone-softening disease that causes severe bowing of the legs, poor growth, and sometimes muscle pain and weakness. Calcium also plays an important part in making sure that muscles and nerves work properly, and in the release of hormones and enzymes."

Non-nutrient Components - Breastmilk contains many other ingredients that cannot be replicated in commercially produced milk, including enzymes, hormones, and immune factors all of which help keep your toddler healthy and growing.

Deciding Between the Alternatives: Animal or Vegan Milk
Toddlers who are breastfeeding at least 3 times a day do not need additional milk. But for those toddlers who have weaned, the American Academy of Pediatrics recommends 3-4, 3oz servings of dairy per day. For parents trying to decide on the best milk for their toddler, here is the nutrient break down:

Cow's milk  - Like breastmilk, whole cow's milk contains high levels of fat and cholesterol, essential for brain building. Grass-fed cows will produce more "good fats" compared to conventional feeds.7 Cow's milk also contains high amounts of protein and calcium for muscle and bone health. Unfortunately, 2.5% of toddlers have dairy allergies. For others, the protein and lactose in milk can be hard to digest since the natural enzymes present in fresh bovine milk have been eliminated during pasteurization.

Goat's milk - Similar to cow's milk, goat's milk contains high amounts of fat, cholesterol, and protein. Some people find that the protein and lactose in goat's milk is easier to digest. However, goat's milk has a flavor that some toddlers dislike.

Vegan "milk" - This category include coconut, almond, soy and most other plant-based "milks." Although these milks are gentle on the tummy and suitable for those with dairy allergies, they contain very little fat, protein and calcium compared to mammal milks. They also contain no cholesterol, which is essential for a toddler's rapid brain growth. Parents whose toddlers do not consume mammal milk (breastmilk, goat, cow etc) will have to work very hard to ensure other sources of these nutrients are abundant in their child's diet.

Nutrition Facts, per cup
Breastmilk is not included simply because the nutrients change over the course of a baby's development, but it would resemble other mammal milks.
   Cow*  Goat* Coconut**  Almond**
 Fat  8g  10g  4.5g  2.5g
 Cholesterol  35mg  25mg  0mg  0mg
 Protein  8g  9g  0g  1g
 Calcium  25%  33%  10%  10%
*whole fat **So Delicious brand, plain, unsweetened

The historical and scientific evidence tells us that it is natural for children to continue to have milk as a primary source of nutrition in their diet for around 3 years. If breastfeeding ends between 12-36 months, I generally recommend parents incorporate at least 3 daily servings of either cow or goat's milk into their child's diet. Of course, in the case of food allergies/sensitivities the vegan milks can be helpful, but other sources of fat, cholesterol, protein and calcium must be carefully added to a toddler's diet in these situations.

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