Vitamin D

Vitamin D is an important nutrient for overall health. It is an important factor in bone health because vitamin D aides in the absorption of calcium and phosphorus. It has also been shown to be important for the immune system, muscle function, cardiovascular function, respiratory system, brain development, and might have cancer fighting effects. It is also believed to be connected to emotional/mental health.
Lack of vitamin D in the winter months has been connected to depression in some people. A major problem that can come from being deficient is rickets. While it isn’t as common in developed countries any longer, it can still happen if a child is not getting enough vitamin D. Rickets happens when bone tissue fails to properly mineralize, causing soft bones and skeletal deformities. This can be mild or extreme.
**Important to note here** Do not freak out that your baby/child has rickets just because they are bowlegged. Baby’s legs are naturally bowlegged and as kids grow, this changes. It isn’t uncommon to go from bowlegged to knock-kneed and then eventually have things even out and look normal. So don’t freak yourself out.
It’s also one of the most common deficiencies. For some people it can be as simple as getting enough sun every week to have optimal levels of vitamin D. It isn’t always that simple though. There are a few factors that affect our ability to have adequate levels from sun exposure; such as, time of day, distance from the equator, skin tone, season, amount of skin exposed, and sunblock use. The link below in the sources section for the Vitamin D Council has more detailed information on this.
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Because vitamin D deficiency is so common, many doctors automatically say that an infant needs to be supplemented. This isn’t always true. If the mother has sufficient levels and both the mother and baby get some sunlight regularly, the baby is likely fine without supplementation. Since it is a common deficiency, many doctors simply assume that no mother will be able to provide enough vitamin D through breastmilk and they recommend supplementation. Your doctor may even say that it isn’t passed through breastmilk at all, which is not true. A simple blood test can be done to test the vitamin D levels in any child or adult. If you are concerned, ask your doctor to do the test and see if you or your baby need to be supplementing.
If you do choose to supplement, there are a variety of brands available, some of which offer the recommended daily dose in as little as one drop.  There are also two types of vitamin D you choose from to supplement with, D2 and D3. D3 is more easily absorbed by the body. However, if you are vegan this may come with an ethical dilemma as it is derived from animal sources. It that applies to you, it is something to take into consideration when choosing a supplement.
Sources:
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Poop – Evidence and Research

Resources Compiled by Pamela Holland, IBCLC
1) Bowel Habits of Normal Thai Infants
2) Jen Tow’s Handout
If you use this, please give credit to Jennifer Tow
3) Bowel Movements and Urination Patterns
Excerpt from: Discharge Procedures for Healthy Newborns, Robert C. Langan, M.D., St. Luke’s Family Medicine Residency Program, Bethlehem, Pennsylvania
Breastfed infants typically have more than three bowel movements per day and are rarely constipated. Watery stool may be normal; however, parents should contact their physician if the infant’s stools run out of the diaper.
Urination Patterns
Six or more wet diapers per day is normal for a breastfed infant after the mother’s milk has come in, as well as for bottle-fed infants
Bowel movements
More than three bowel movements per day is normal in breastfed infants.
Bottle-fed infants may have fewer bowel movements
4) Factors associated with defecation patterns in 0–24-month-old children
European Journal of Pediatrics; http://link.springer.com/journal/431; December 2008, Volume 167, Issue 12, pp 1357-1362, Date: 09 Feb 2008
Abstract
To identify the normal defecation patterns and the factors affecting these patterns in the first two years of life, a questionnaire was given to the parents of 1,021 children who were followed in a well-child clinic. The time of first meconium passage, presence of colic symptoms, frequency, color, and consistency of stools were recorded. Mann Whitney U, Wilcoxon, chi-square, and correlation tests were used in the statistical analyses. The median number of defecations per day was six in the first month of life. This decreased to once in the second month and almost all cases remained so until the end of the 24th month. At the second month of age, 39.3% of infants passed stools less than once a day. This pattern of rare defecation was seen until the end of 6 months, when supplemental foods were started. Stool frequency was higher in exclusively breast-fed infants (p = 0.0001). Infants who had colic symptoms in the first 2 months had less frequent defecation during the first 2 years of life (p = 0.0001). In addition to confirming the previously observed defecation patterns of 0–2-year-old infants, this study provides the relationship between colic symptoms and stool frequency, and showed that the second month of life was unique in the sense that the frequency of stooling decreased to half of the previous month and 39.3% of these infants defecated less than once a day.
5) Frequency and weight of normal stools in infancy.
Arch Dis Child. 1979 Sep; 54(9): 719–720. PMCID: PMC1545825,  J N Lemoh and O G Brooke

Bottle Feeding the Breastfed Baby

Read through this helpful site:
Show this video to ALL caregivers:

Paced Bottle Feeding

As we know, breastfeeding is not just nourishment. The leisurely pace of breastfeeding allows a baby’s brain to realize his stomach is full before he is overfull.
Paced bottle feeding is designed to mimic the “conversation” of breastfeeding. This helps avoid overfeeding via bottle, and allows mom’s supply to keep up with the amount fed to baby via bottle.
Most breastfed babies eat 19-30oz in a 24 hour period. This amount easily meets the caloric needs of the vast majority of babies.

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What Bottle is the Best?

You likely don’t need to spend a ton of money on bottles. Use a standard bottle and the slowest flow nipple (premie or size 1). Every mom/baby will tell you a different bottle that worked for them. Trial and error will tell you what works for your baby.

How Long Should it Take to Feed a Bottle?

It should take at least 5 minutes per ounce of breast milk, or about 15 minutes for a 3oz bottle.

How Much Milk?

1-1.5 Ounces per hour, on average.
Make bottles small to start, 2-3 ounces, to reduce milk waste. Bottle size should not typically exceed 5 ounces. Formula bottles are a lot bigger, so caregivers may be confused and recommend you make bigger bottles. Gently explain to them why this is not ideally. Giving them the tear sheets linked above might help!
Read this site for more details on how much milk to give:

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When to Feed?

Feeding your baby on demand is the best way to meet baby’s needs- offer milk before the baby starts to cry and root. It takes several minutes to warm and prepare a bottle, so be ready to feed when baby is ready. Most babies eat at least every 2-3 hours.
Young babies will want to nurse to go to sleep. Train caregiver to recognize your baby’s sleep signals and to get them to sleep before they are overtired.
Here is more information on hunger cues: http://kellymom.com/bf/normal/hunger-cues/

How to Determine Feeding Schedule:

Can you nurse at drop off and pick up? Can you visit baby on your lunch break to nurse?
This will reduce your pumping needs and the amount of bottles required. Plan extra time to nurse.
Plan for first bottle to be given 2-3 hours after last feeding. And then every 2-4 hours after.
Let caregiver know what time to not feed after. Call ahead and let them know you are on the way and not to feed the next bottle, if necessary. You are in control of the feeding schedule!
Only leaving for a little bit? Nurse before you leave and as soon as you get back!

Do I Need to Practice?

Yes! But let your partner or other caregiver (grandparent, friend) feed the bottle when you are NOT in the room. Babies know when their mother is nearby and know they can nurse. Leave a soiled shirt that has your scent for use. Have caregiver put it over their shoulder.

Help! My baby won’t take a bottle!

Check out these tips to help your baby take a bottle or take expressed breastmilk from a cup or spoon.
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Bottle feeding is a normal part of breastfeeding life for many moms and babies in the 21st century. Learning to properly pump and bottle feed can offer you the freedom to be away from your baby for a date night, to return to work or school, or for some much needed self care. Rest assured, you will figure it out and your baby will be taking a bottle in no time.

Storage of Breast Milk

Storage Guidelines of Expressed Breast Milk:

Freshly-Expressed Milk
               Warm Room : 3-4 hours
               Room Temperature: 4-8 hours
               Insulated Cooler/Ice Packs : 24 hours
Refrigerated Milk
               Refrigerator (fresh milk) : 3-8 days
               Refrigerator (THAWED milk) : 24 hours
Frozen Milk (do not refreeze!)
               Self-Contained Freezer of Refrigerator : 6 months
               Deep Freezer : 12 months

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Mixing Expressed Milk:

Only mix milk at or near the same temperatures.
Freshly-expressed milk can be added to room temperature milk within 4-8 hours. Otherwise, refrigerate milk and then combine. Add refrigerated or partially frozen milk to already frozen milk.

Oops! I didn’t use/need what I HEATED!

Thawed milk needs to be used within 24 hours. Keep refrigerated until next feeding. Heated or warmed milk needs to be used within 2-3 hours. Simply smell milk if you think it may be bad. Don’t toss the milk! Use “bad” milk in the baby’s bath!

Does the milk have a metallic taste or smell funny?

See link for more info:

Helpful Information:

CDC Recommendations:

The STUDIES the Storage Guidelines are based on:

Nipple Shields – A Note from our IBCLC

Consider this a PSA about nipple shields. Nipple shields can be a valuable tool for certain breastfeeding problems.

Here are a few examples of those problems:

  1. Preterm babies, some studies have shown that a nipple shield can be effective when working with babies that aren’t term.
  2. Babies with tongue tie, if you are waiting on a referral to get a tongue tie revision a nipple shield can be helpful and it extends far enough into the baby’s mouth to maintain latch.
  3. Babies with poor muscle tone can sometimes benefit from the rigidity of the shield.

 

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Here are some reasons NOT to use a nipple shield:

  1. Baby will not latch, if you are using a shield, baby is still not latched.
  2. Breastfeeding is painful, if breastfeeding is painful it is because baby isn’t latching well. If you are using a shield, you still have a baby that is not latching well only now it is to the shield.
  3. Baby keeps coming off the breast, if baby stays on with the shield, please have infant evaluated for tongue tie/lip tie.
  4. If you are using a shield for any reason, please note that there is s good chance that your milk supply will diminish over time. This is because your baby’s saliva doesn’t come in contact with your nipple and stimulation is decreased by the layer of silicone.
I like to think of nipple shields the same way that we would consider antibiotics. With judicious use, they truly can be a lifesaver. But most of the time they are not necessary and they certainly aren’t going to do a thing for the common cold (or sore nipples).
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Birth Control and Breastfeeding

Most methods of birth control are not harmful to nursing infants but any hormonal birth control can cause issues with milk supply. Progestin-only birth control is generally considered breastfeeding compatible, but combination birth control (containing estrogen and progestin) is typically not recommended.

Breastfeeding can cause the delayed return of fertility for some mothers, but only if certain conditions are met. Like any method of contraception, there is a certain rate of failure and many factors can affect the success rate. Check out the graphic below for more information on this method.

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For more information on hormonal birth control:

 

Long-acting Reversible Contraception (LARC) Methods

LARC methods include the intrauterine device (IUD) and the birth control implant. Both methods are highly effective in preventing pregnancy, last for several years, and are easy to use. Both are reversible—if you want to become pregnant or if you want to stop using them, you can have them removed at any time.

The IUD is a small, T-shaped, plastic device that is inserted into and left inside of the uterus. There are two types of IUDs:

  1. The hormonal IUD releases progestin. One hormonal IUD is approved for use for up to 5 years. Another is approved for use for up to 3 years. The progesterone-releasing IUD delivers its hormone directly to the lining of the uterus, which only leads to a slight increase in progesterone levels in the blood stream (much lower than that found with the progesterone-only pill). As a result, there is much less chance of side effects from the progesterone than from the injection or mini-pill.
  2. The copper IUD does not contain hormones. It is approved for use for up to 10 years.

The birth control implant is a single flexible rod about the size of a matchstick that is inserted under the skin in the upper arm. It releases progestin into the body. It protects against pregnancy for up to 3 years.

For more information on LARC:

 

Other Methods

Other birth control options include barrier methods and fertility awareness methods. They are not harmful to nursing infants and don’t affect milk supply.

For more information on other birth control:

Whatever method of family planning you choose, we love to recommend that any person with a uterus read the book Taking Charge of Your Fertility, to better understand your reproductive system, and truly take charge of your body.

Jaundice

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Often, one of the first challenges a mother faces is jaundice. Doctors and nurses may indicate that all jaundiced babies must be fed formula, but evidence suggests that this is not case. Infants can absolutely overcome jaundice and grow into healthy babies while consuming only breast milk. Although management of breastfeeding and jaundice varies among the nations, the principles and recommendations outlined in the link below apply universally.

Click here to read through the Academy of Breastfeeding Medicine’s Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation.

Lactation Professionals and Resources

Support is key to the success of any breastfeeding relationship. It truly takes a village! Use the links and resources below to find a lactation professional or breastfeeding support group near you.

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Why an IBCLC?

An Internationally Board Certified Lactation Consultant (IBCLC) is a highly trained lactation professional. IBCLCs spend hundreds of hours studying the biology and best practice of lactation, and are certified by the IBLCE, which establishes the highest standards in lactation and breastfeeding care worldwide. There are many wonderful CLE and CLCs out there, but IBCLCs undergo a uniquely rigorous and thorough course of training to receive their certification. Overall, their knowledge tends to be more complete and up to date.

 

Savannah, GA Resources

We have 3 IBCLCs (all in the Savannah/Statesboro area of GA) in the Milky Mommas group. These ladies are amazing and can literally turn your breastfeeding relationship from a nightmare into a dream come true:

Pamela Holland www.facebook.com/pages/Lactation-Home-Visit-LLC/197778186929809

Nancy Derr www.facebook.com/SoutheastGeorgiaLactationAndWellnessServicesLlc

Helen Pastures https://www.facebook.com/LatchSAV/

Find an IBCLC in Your Area

http://www.ilca.org/why-ibclc/falc

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La Leche League

There are local La Leche League meetings in every state. Many groups have local Facebook pages.

See link below to find your local group:
http://www.llli.org/webus.html

  • Call the Leader Locator at 847-519-7730. This number provides access to an automated system for finding LLL Leaders in the US by entering a local zip code. In Canada, call 800-665-4324, or 514-LA-LECHE for a French-speaking Leader.
  • If you are unable to find a Group or Leader near you, 24-hour breastfeeding help is available toll-free in the US from the LLL Breastfeeding Helpline-US at 877-4-LALECHE (877-452-5324).

If you are local to Savannah GA, here is the LLL of Sav page: https://www.facebook.com/lllsavannah.

 

Breastfeeding USA

The mission of Breastfeeding USA is to provide evidence-based breastfeeding information and support, and to promote breastfeeding as the biological and cultural norm.

Find a Breastfeeding USA group in your area:
https://breastfeedingusa.org/content/breastfeeding-counselor-locations.

 

 

How to Become an IBCLC

If you are interested in becoming an IBCLC, you can find more information here:
http://iblce.org/certify/preparing-for-ibclc-certification/.

If you have worked with an incredible IBCLC or LLL in your area, feel free to share their link with us. The more resources we have, the more support our fellow Milky Mommas will have on their amazing breastfeeding journey.

Low Milk Supply

One of the most common concerns of the breastfeeding mother is that they aren’t making enough milk for their baby. Let me assure you, true low supply, or the inability to produce adequate milk, is rarely the problem. What signals your body to make more milk? Removing milk!

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“But he wants to eat all the time!”

Ok…Let’s look at the whole picture:

  • Is baby very young? Newborns have a stomach that, at 10 days old, is still only the size of an egg, and he’s eating a perfect food that is completely digested quickly.
  • How old is he? Just like a teenage boy that eats all the time, babies are growing…and fast! There are several physical and developmental spurts that occur, usually around the same time for each child. Take a look at the Wonder Weeks chart (http://www.whosthatmom.com/wonder-weeks-week-by-week/) and see if your baby is either having a growth spurt or about to have one.
  • Is he latched correctly? Can you hear him swallowing? A proper latch is comfortable for you, not painful, and allows baby to efficiently remove milk from the breast. If you have access to an IBCLC, have them check baby’s latch. There are several valuable resources here, as well: http://kellymom.com/ages/newborn/bf-basics/latch-resources/

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“He fusses at the breast. I don’t think any milk is coming out.”

  • Let’s talk about supply and demand. Babies demand milk…and you supply it. Fussing at the breast, beating on you, on-and-off nursing, etc, all signal your body to make more milk. Your breasts don’t ever truly become “empty”, they continuously make milk.
  • Does he need to burp? Is he distracted or overstimulated? Are you distracted or stressed?
  • Is he getting too much milk? Check our document on oversupply to see if it sounds like you.

“I’m pumping barely anything.”

  • Pumping is never a good way to judge what you’re actually producing. Babies are much more efficient at getting milk out than a pump.
  • Also see our document on Pumping Tips for help when pumping at work.

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“My breasts feel empty. I think my supply dropped.”

  • Probably not. Most of us only experience super-full feeling breasts for a limited time. What is most likely happening is that your supply is regulating. Your body and your baby’s demands have come to an understanding and your are meeting his needs without becoming overfull.
  • Your breasts always make milk. When milk is removed, they make more. “Your breasts are a factory, not a storage facility.” They are never truly empty.
  • Babies can typically always get out more milk. Even if it’s minimal; they are very efficient at their job.

“How do I make more milk?”

  • Firstly…nurse your baby more. Most concerns about supply can be fixed by simply nursing more.
  • Nurse baby on demand. Let him decide when he wants to eat.
  • Pay attention to baby’s hunger cues. Rooting, smacking lips, sucking hands, etc, are all signs of hunger. Crying is a late hunger cue.
  • Soothe at the breast. Comfort nursing can be frustrating sometimes, but it is the best means of comforting your baby and ensuring an abundant supply of milk.
  • Nurse until baby lets go. Let him decide when he’s done.
  • Don’t be a clock-watcher. Allow baby to run on his own time.

Signs that your baby is getting plenty of milk:

Birth-2 weeks:

  • baby starts gaining weight after your milk comes in. Remember, weight gain varies with every individual. Don’t compare your baby to your friend’s or yourself.
  • baby is having at least 3 quarter-sized poops per day. These can be spread out over a 24 hour period. More than three is fine.
  • baby is swallowing when he’s nursed.
  • baby is nursing at least every three hours until he reaches about 10 pounds. Again, more is fine.

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2-6 weeks:

  • baby passes birth weight by around 2 weeks. Remember to calculate that by baby’s lowest weight.
  • baby continues to gain weight.
  • still has 3 quarter-sized poops per day. Until around 6 weeks, this is what we want to see. Others may tell you that it is normal for exclusively breastfed babies to go several days or even a week or more without pooping. That is not true until around 6 weeks, and even then, not the norm.
  • baby has gotten the hang of latching on and staying attached.
  • baby is sucking with long, steady sucks soon after latching.

6 weeks on:

  • baby continues to gain weight.
  • baby is meeting developmental milestones.
  • baby has plenty of wet diapers and regular poops (they become less frequent around 6 weeks).
  • baby is getting longer and gaining in head circumference.

What if your supply is truly low?

Sometimes baby really isn’t getting enough milk. It’s important to understand why.

It’s important to figure out if he’s not taking enough because you’re not making enough, or if you’re not making enough because he’s not taking enough, or if he’s taking plenty but not using it well.

Source: The Womanly Art of Breastfeeding, 8th ed., p.396

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What might be the issue with baby?

Possible causes of baby taking too little milk are:

  • he’s improperly positioned
  • his nursing time is being cut short
  • he’s being fed too infrequently
  • he has a tongue-tie or other latching issue

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What might be the issue with me?

Possible causes of mother making too little milk are:

  • thyroid problems
  • PCOS (Polycyctic Ovary Syndrome)
  • breast surgeries

If your supply is truly low and your baby is not thriving, it is our advice at Milky Mommas to seek out and meet with an IBCLC to identify and correct the problem.

Most of these scenarios are completely reversible, so don’t give up hope. Remember, if you must supplement due to medical indication – and at the recommendation of a professional – there’s a strong chance that supplementation need be only temporary and you can return to being your child’s sole source of nutrition.

Teething and Biting

Sooner or later, all babies and toddlers will start teething. Many breastfeeding moms fear this milestone due to the “danger” of biting. However, teething is no reason to wean! Millions of mothers comfortably nurse babies and toddlers with teeth every day. With these tips, you can too.
Teething signs can start early (2-3 months old) but an actual tooth may not appear until months later. Not all babies show the same signs when teething and any of the symptoms below can be a sign of teething.
Signs your baby is teething may include:
  • A tooth visible below the gum
  • Swollen, bulging gums
  • Trying to bite, chew, and suck on everything she can get her hands on
  • Drooling
  • Irritability
  • Rubbing her face
  • Difficulty sleeping
  • Turning away food
  • Grabbing at the ears
If you observe several of these symptoms together, the likelihood that teething is the culprit is higher – but there’s always the chance that something else is to blame. Low grade fever can also be a sign of teething, but look for other signs to ensure the fever is not associate with a virus (runny nose, cough, etc).
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Remedies
  • A clean cold wash cloth
  • A clean cold wash cloth that has been in the freezer for a bit
  • Frozen fruit like an apple slice or berries in a mesh holder (for those over 6 months and already on solids)
  • Milk-sicles (breastmilk frozen in a popsicle mold or ice cubes in a mesh holder)
Essential Oils and Tylenol/Acetaminophen are no longer recommended as remedies.
Many essentials oils are not considered safe for children under the age of 2, hence the reason they are no longer recommended.
Tylenol is no longer recommended as a pain reliever by the FDA. It is still considered a fever reducer but new guidelines recommend using it sparingly or skipping it all together.
“The FDA’s Nonprescription Drugs Advisory Committee and Pediatric Advisory Committee have together recommended that “pain relief” be removed from the label of Tylenol for babies and toddlers and other brands of acetaminophen because there is no reliable evidence that it relieves pain better than placebo in children under age two.”

Biting
Sometimes teething babies will bite in order to soothe gum pain, or bite playfully. There are many methods for dealing with this, some better than others. Try out these tips to prevent your nursling from biting!
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