Over and Under Supply of Breast Milk

New moms often worry that they won't have enough milk for baby. Most moms have plenty of milk, but working with nurses or doctors who have been trained to help with lactation and following weights of your baby is important until breastfeeding is well established. In some instances we also check blood sugars and other indicators of hydration. I always try to support breastfeeding, but there are some instances where a baby will require a supplemental formula to avoid further medical complications.

photo source: Shutterstock

It is normal to lose weight the first week of life. Babies are born with excess water weight, making them look a bit puffy, but this allows them to stay hydrated until milk comes in. Most babies lose between 6 and 8% of their birth weight, but there are normal variances. A great resource to see if they are within the acceptable weight loss is the Newborn Weight Tool. Once they start gaining, they tend to gain 15-30 grams per day until about 4 months of age.

How much milk is there?

Once milk supply is established, it is constantly being made. The breasts are never completely empty. It is common for one breast to make more milk than the other. This does not indicate over or under supply as long as the combined amount is sufficient for baby to grow. In general the more a baby feeds, the more milk is made. It is not recommended to wait longer between feedings to have more milk per feed. This actually backfires because your breasts sense that baby doesn't need to eat as much, so will make less overall milk.

Initially there is only a few milliliters of colostrum for each feed. Once milk comes in, there will be a couple ounces total. This increases as baby feeds more, such as during growth spurts. Your body should respond to baby's needs.

Peeing and pooping

We monitor urine to be sure babies stay hydrated. I use the 1, 2, 3 rule.

• 1. The first 24 hours of life baby should pee once. 
• 2. The 2nd 24 hours baby should pee twice.
• 3. The 3rd 24 hours baby should pee three times.
• By the 4th day milk should come in and the wet diapers will increase. Most babies will need to be changed with each feeding.
• Disposable diapers have super absorbent gel that make it really difficult to see small amounts of urine. (When older babies have a soaked diaper you might notice these gels look like crystals - some parents worry about kidney stones when they see these. Nope. Just super absorbent gel crystals that escape the diaper!) If you're having a hard time telling if there is urine in the diaper during the first few days, put a piece of toilet paper in the diaper. Don't count on the color indicator strip (found on some diapers) to know if the diaper is wet or dirty - there's often not enough wetness to make these work initially. 

Stools change quite a bit during the first week of life and then again over the initial months.

• Meconium (thick, black tar like stools) is common the first few days. If baby doesn't have a meconium stool within the first 24 hours of life talk to baby's doctor.
• Once all the meconium is out, some babies don't poop for a day or two. It takes time for the milk to go through. This is fine as long as breastfeeding is otherwise going well!
• Green stools are common during the transition from meconium to breastfeeding stools.
• Breastfeeding stools look like yellow cottage cheese - watery with flecks of solid pieces (this is why they are called seedy). Many parents think it looks like diarrhea, but it's normal. 
• Breast fed babies often stool multiple times a day initially, but then can develop a pattern that they only stool once a week (sometimes even less often). As long as the stools are soft when they come out, it is okay. 
• Most babies grunt and groan during bowel movements. Some even get red in the face. This is not constipation. They are just learning to bear down and poop. 

Engorgement

When milk first comes in the breasts often feel hard and swollen. This is normal and typically improves over time. It does not indicate that there is too much milk. Breasts must adjust to milk production, so can feel very full when they are not. You can get relief from warm compresses for 5 minutes before each feed, feeding frequently, changing baby's position with each feed, and massaging breast tissue during feeds. Some women like to use cold compresses between feeds for 20 minutes at a time. You can also take ibuprofen for pain. Briefly hand expressing milk or pumping before breastfeeding can be helpful. Excessive pumping can lead to more milk production, so use this only to soften the tissues to allow for a better latch when feeding unless you're trying to increase milk supply or begin storing milk.

Is it normal to feed so often?

Most newborns will feed 8-12 times in a 24 hour period. Since feedings and the associated diaper changes, burping, and everything else can take an hour or so initially, it does seem like they are constantly feeding. Many babies will cluster feed, which is when they stack feedings closely together at a particular time of day. This is often in the evening and can help them sleep longer stretches at night. 

How do I know when milk comes in?

The first few days there is colustrum to nourish baby. This is usually sufficient until milk comes in, typically when baby is 3-5 days old.

When milk comes in some mother's feel their breasts harden and swell, but not all mothers feel this. You might feel baby sucking and hear swallowing in a different pattern once milk comes in. The amount of urine baby makes will increase when milk is in, both in the number of wet diapers and the volume in each diaper.

Nipple Confusion

A lot of lactation experts warn about nipple confusion, but I don't find that it causes problems in most babies if they use artificial nipples, especially pacifiers.

Pacifiers, AKA binkies, can help soothe a fussy baby between feeds. They have been shown to reduce the risk of SIDS, though it is not known how. Studies are inconclusive as to whether or not they affect breastfeeding success. The suck on a pacifier and the suck on mother's nipples are very different, but I have not seen many babies get confused when offered both. If baby has a good latch and breastfeeds effectively, there is no reason to avoid pacifiers in my opinion - which is shared by others. (This differs from the American Academy of Pediatrics position to wait until 3-4 weeks of age.) Babies are seen to suck on fingers and arms while still in the womb... if they need to suck, it is okay for them to suck. If a pacifier helps between feeds to give mom's nipples a break, great! I actually find that this break helps mom want to breastfeed and not give up as easily. Don't use the pacifier to delay a feed though - if baby's hungry, feed him! Of course, if the use of a pacifier seems to affect their feedings, then stop their use until breastfeeding is well established.

Bottles are a means of nutrition. Most breastfeeding babies won't need to take a bottle until breastfeeding is established, but if a baby is failing to get sufficient hydration or nutrition from the breast supplemental nutrition is important. I do see some issues with latch and biting if baby gets used to biting on a bottle's nipple, though not every baby has problems. Many can go back and forth from breast to bottle easily. If you're worried about nipple confusion and your baby needs supplemental nutrition, you can spoon feed or use a syringe to put the milk into baby's mouth. Some mother's will use a supplemental nursing system provided by a lactation nurse. If you are using a bottle for nutrition, it is important to pump so that the breasts are stimulated to make milk for baby.

On the flip side, if breastfeeding is going well, don't forget to start a bottle between 3 and 6 weeks. Mothers who wait longer often find that baby won't take a bottle at all, which makes returning to work or leaving baby for more than an hour or two difficult.

Overproduction of Milk

I always say that too much breast milk is a good problem to have. It's good because it's often easier to handle than too little milk, but it's still a problem.

Too much milk can lead to baby not emptying the breast sufficiently, which can lead to clogged milk ducts and mastitis. You might notice a firm area in the breast that didn't empty during a feed. If this becomes red, painful, or is accompanied with fever or flu like symptoms, see your doctor.

It can also allow them to fill up on fore milk, which is lower in fat than hind milk (which means fewer calories per ounce), so baby can be well hydrated but under nourished.

There also can be increased lactose in fore milk, which can lead to gas, fussiness, and even more watery than normal stools. Many people see more green in the stool, but stool color can also vary with mother's diet.

These babies often only need to feed for a short period of time, but more often than other babies because they fill up quickly, but the low calorie content of the milk leaves them hungry in a short period of time.

Because there is oversupply, these babies may choke when feeding if the milk comes out fast. They may pull off or clamp down. To help with this, try side lying position of feeding or sit in a reclined position during feeds.

Working with your pediatrician and a lactation specialist to ensure adequate weight gain is important with overproduction because baby is feeding well and satisfied after each feeding so it is difficult to be sure the calories he is getting is sufficient. 

Tips and tricks used:

• Express 1/2-1 oz of milk before the feed to allow baby to get some hind milk. (Store this in the freezer for future use!)
• Feed only from one breast per feed to decrease overall supply. Usually within a week supply will begin to decrease, and you might need to feed the second side if baby shows hunger cues after eating from the first side.
• Pumping about an hour before the next feeding can remove some of the excess milk. 
• Sometimes hormone therapy (birth control pills) or other medicines are used to decrease supply.

Low Milk Supply

It is very common for mothers to worry about not having enough milk for their baby. The first few days most babies only need a teaspoon or so of colostrum per feed. Most babies do not need to supplement with formula until milk comes in. 

Breastfeeding 8-12 times per 24 hours will help establish healthy milk supply. Feed from one breast completely before changing to the other side, and alternate which side you start each feeding. The more you feed (or stimulate the breast with pumping), the more milk you'll make. You can pump between feedings or for 5 minutes after each feed. Feed baby anything you pump if he's still hungry after breastfeeding! See "Nipple Confusion" section above for information on giving expressed milk.

Milk supply can be affected if you have had medical complications of pregnancy, are excessively tired, are not properly nourished, start hormonal birth control or have certain medical conditions. Some medications (especially for cough and cold)  and some herbs can decrease milk supply. Talk with both your obstetrician and baby's pediatrician about any milk production concerns. 

In general you will need about 500 calories per day more than your baseline to make milk. You will also need to drink plenty of water -- keep your urine pale, not too yellow! 

Sleep helps! I know it is difficult to get enough sleep when baby eats every 2 hours, but nap throughout the day as much as possible. 

Galactagogues are compounds that boost milk supply. Many are sold over the counter but should only be used if other means of increasing milk have not worked well enough. Talk with your OB and pediatrician if you are using any of these:

• Fenugreek (do not use if diabetic or allergic to chick peas or peanuts): 

• Tea - 1 cup three times daily
• Capsules 1500- 2000 mg three times daily 

• Blessed thistle or Milk thistle (can be used with fenugreek but is very bitter)

• Tea - 1-2 tsp in cup of tea three times daily
• Capsules 800-1000 mg three times daily

•  Alfalfa  

• Tea - 1-2 tsp in cup of tea three times daily
• Capsules 2000 mg three times daily

•  Anise

• Tea - 1-2 tsp in cup of tea three times daily

• Oats (you can do this one regardless of milk production since it can be part of a healthy breakfast)

• One bowl oatmeal a day (avoid the little packets with added sugars)

•  Goat's Rue

Tea - 1 tsp in cup of tea three times daily

For more information:

Kelly Mom is a fantastic breastfeeding resource. You might have noticed that I linked several of their pages above.

My child won't eat... what should I do?

I hear from worried parents often that their kids won't eat. There are many reasons for this. Usually as long as a child is hydrated, gaining weight appropriately, and getting a variety of nutrients, I am not worried.

Some reasons kids don't eat:

• They're really getting enough food, parents just have unrealistic expectations. This is very common. Portion sizes are smaller than many parents think. They vary with age and size of a child as well as his activity level. If your child is growing well and has plenty of energy throughout the day, why should he eat more? Kids tend to eat small meals frequently and even on holidays they don't overeat like the adults tend to do. When offering snacks, think of them as mini meals to help balance out the nutrients of the day. Don't let them snack all day long though or they'll never really be hungry. Schedule meals and snacks and allow water in between. We have an obesity epidemic in this country, so if you're comparing your child to another child, chances are that your thin child is healthy and normal, but the other one is one of the 30% who is overweight. Or maybe not. It doesn't matter. Just be sure your child is getting a proper variety of nutrients, he should determine how much to eat. Talk to his doctor about his growth at regularly scheduled well visits (more often if you're concerned) to be sure it's appropriate.
• They're sick and it's temporary. When kids are sick they lose their appetites. This is normal. It usually returns with a vengeance when they're feeling better. They need to drink to stay hydrated and can eat what they feel up to it, but don't force it. See their doctor if you're worried.
• It's a new food and they just aren't sure yet. I encourage that kids over 3 years old take one bite of a food. Kids often hear me say, "taste a bite without a fight." The bite needs to be enough that they taste it. If they like it they can keep eating. If they don't want more, resist trying to convince them to eat more. Allowing them to take ownership of the decision of what to eat empowers them. Kids like power, right. Give it to them while modeling healthy eating behaviors yourself. They learn from what you do, not what you say -- and not from what they're forced to do. When preparing a new dish, include familiar foods they like to balance out the meal so they can enjoy at least something on the plate.
• They're picky eaters. Aren't they all? Most kids go through phases where they love a food then they suddenly dislike it. They might dislike a certain texture or a whole food group. While there are kids with real problems eating, most picky eaters can be encouraged to eat a healthy variety of foods as described above. Some children really suffer from being overly restrictive. Children with autism, sensory problems, food allergies, and other issues are not included in this "typical" picky eater category. A great series of blogs on picky eaters (typical and more concerning) is found on Raise Healthy Eaters. 
• They're more interested in something else. Make meals an event in itself. Sit together and talk. Turn off the television. Put away your phone. Have everyone focus on the meal, which includes the food and the conversation. Try to keep the conversation pleasant and not about the food. Take the pressure off eating!

In general, parents should choose what foods kids are offered so that there's a balance of nutrients, but kids determine how much they eat. If they're hungry, they'll eat. If they're not hungry, they shouldn't eat. Learning to eat when not hungry is something that causes many of us to struggle with weight. Most kids are able to limit intake to needs. Don't force them to change that great quality!

For more, see my other blogs on the subject:

• Nutrition for the Picky Eater
• Taste a Bite Without a Fight
• Food Strike!
• Kid's Weight Is Weighing On My Mind

Nutrition For the Picky Eater

I am frequently asked about how to get kids to eat. In general, there are a few quick "rules":

• Don't offer junk. Don't make it easily available at home... most kids can't drive to the store!
• Hungry kids will eat what's offered. Let them get hungry between meals. No grazing.
• Not every food group will be eaten at every meal, so use the day to space foods to incorporate a range of nutrition over time. Think of snacks as mini-meals.
• Keep meal time fun.
• Enforce "Taste a bite without a fight" after 3 years of age.
• It's okay to be tricky and fun: add pureed vegetables to things, use yogurt or hummus dips, put food on a stick, arrange food into fun shapes, be creative.
• Juice is not a food.

This is my first attempt at adding video to my blog. I apologize for the tilted view... it looked straight on my camera! YouTube limits the length to 10 minutes, and I ended up at 11 minutes, so it is broken into two shorter segments.

Part 1:



Part 2: 

Resources mentioned at the end:

My Pinterest page has several boards with recipes and nutritional information, in addition to other kid-friendly ideas! (Warning: if you don't use Pinterest, it can be addictive. Tons of great project ideas and recipes, educational sites, and other time wasters...)

Kids Eat Right: The Academy of Nutrition and Dietetics' page on scientifically-based health and nutrition information you can trust to help your child grow healthy.

New Year's Reflection

I was fortunate to be able to spend New Years with my extended family in the St Louis area.  Conversation led to my mother remembering old family videos in the basement. After a little digging around, my brother found the never before seen footage!

We had a blast watching videos of past holidays and vacations.

Some things were fun to compare. My daughter is better at ballet than I was at her age.

Other things were simply laughable.  Although I was impressed at my grandmother looking fit and trim in short shorts, most clothing choices of the 70s should never be repeated.  What will they think of our current clothes in 30 years?

One thing that struck me sadly was the average weight of people at all ages in the 70s seemed to be less than the average weight of people the same age today.  I'm not saying my friends and family have gained weight ~ I would get into trouble for that!  It was simply noticeable that people of today are heavier when comparing large groups.

I've read the statistics before...

Self Reported Weight up Nearly 20 Pounds Since 1990
Mean Body Weight, Height, and Body Mass Index, US 1960-2002

... but it was interesting to see large groups of people from my past vacations and comparing to what I see daily when out and about.  It made it real.

If the US is such a great nation, how have our individuals as a group gained weight in this unhealthy manner?

Is it the convenience of pre-packaged foods, many of which are processed and/or high in fat?   More women work now than previously. Does this contribute to less home-cooking and more fast foods?

Is it that the meal size increasing?  Large sodas of my childhood are now the smallest size available.  Who needs 64 ounces of acidic bubbly sugar?  We eat larger servings both at home and at restaurants. 

Are we less active than we used to be?  I can easily see how today's kids are tempted with tv, video games, and other sedentary activities.  As a child, I only had one tv channel, and most often it had adult programming. (There were no recordings available!) I had many other things to do both in the house and outside.  We didn't have many structured activities, so we just made it up as we went along.  And we had a blast!   What about adults? Are they less active? Do we work more hours than our parents?  Do we spend more free time in front of the tv/computer than our parent's generation? What did they do for fun?  Was it out of a chair?

Do we sleep enough? With many tasks to do and distractions, such as tv programming and internet available all night, do people stay up too late to get a good night's rest?  More and more research supports that sleep is needed for concentration, endurance, immune functions, as well as weight control and more.  How often do we feel tired?

I suspect that there are many reasons for our generalized weight gain, which means that there are many potential fixes, and not one alone will help.  I have tried to limit processed foods at home, but they are convenient and easy, so I sometimes splurge.  We try to eat as a family at home most nights, though activities sometimes interfere.  Portion control is relatively easy for my kids: they eat minimally by nature.  My husband and I need to check ourselves.  My kids are much better at exercise than I am, mostly because they have time and they love to move!  I don't want to forego sleep to fit in exercise. No one gave me time for Christmas... but I'm working on finding some free time!

What do you find helps keep your family healthy?

  

Kid's Weight is Weighing in my Mind

Reports of increasing obesity levels have been circulating for years on the news.  I see kids in my office regularly who are in the overweight or obese category and we all struggle how to treat this growing problem.  Excess weight in childhood is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty- leading to overall shorter adult height.  Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Why is weight so much more of a problem now than it was years ago? As a child I did not have a perfect diet, yet I was not overweight because we spent most waking moments outside if we weren't in school. My mother packed a dessert in every lunch box.  We ate red meat most days.  We usually had white bread and butter on the table at dinner.  We drank 2% milk and I ate ice cream every night.  But we walked to school-- without a parent by the time I was in 1st grade (gasp!)  There were only a couple tv channels, and Saturday morning was the only time we could watch tv.  We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it - we found something to make it fun!  Today's kids are shut up in the house after school watching one of many tv channels or playing video games. Even those who are shuttled to activities get overall less exercise because it is structured differently.  They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction. Simply put: they don't get to do things at their own pace with their own creativity for as long as they want.

What to do???  On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders.  I think this is possible if we focus on the word healthy, not weight.   Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall.  If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI.  We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.  I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

1. Healthy eating
2. Exercise (with proper safety equipment- but that's another topic!)
3. Sleep (again, another topic entirely!)

Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.  If we are lucky our kids like one or two vegetables and some fruits.  We might even be able to sneak a whole grain bread in the mix.  If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about).  We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want.  We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy.  The perception of calorie needs and actual calorie needs can be very mismatched.  I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:

• turn on the tv and feed the child while the child is distracted
• reward eating with dessert
• refuse to let the child leave the table until the plate is empty
• allow excessive milk "since at least it's healthy"
• allow snacking throughout the day
• legitimize that a "healthy" snack of goldfish is better than cookies

Any of these are problematic on several levels.  Kids don't learn to respond to their own hunger cues if they are forced to eat.  If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?  If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating.  They can, however, over time slowly kill themselves with unhealthy habits.  

So what does your child need to eat? Think of the calories used in your child's life and how many they really need.  Calorie needs are based on age, weight, activity level, growing patterns, and more.  

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.  Do parents realize how damaging this can be?  

• A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
• A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
• A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
• Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.

Now consider those famous treats at games.  Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:

• Typical flavored drinks or juice range 50-90 calories per 6 ounce serving. 
• Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
• Fruit roll up (28g) 104 calories
• 1 medium chocolate chip cookie: 48 calories
• Orange slices (1 cup): 85 calories
• Grapes (1 cup): 62 calories
• Apple slices (1 cup): 65 calories

So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.  The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.  And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...

What's wrong with WATER?  And eating real food after the game.  As a family. Around the table.  That snack is likely to decrease appetite for the next meal, and it isn't needed.  And if they're hungry, they're more likely to eat the healthy foods on their plate.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.


Simple suggestions:

• Offer a fruit and vegetable at every meal. Fill the plate with various colors!
• Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways - like with a toothpick. Don't forget to lead by example and eat your veggies!
• Buy whole grains. 
• Choose lean proteins.
• Eat together as a family as often as possible.
• Turn off the tv during meals.
• Encourage the "taste a bite without a fight" rule for kids over 3 years. But don't force more than one bite.
• Don't buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren't in the home, they can't be eaten!
• Drink water instead of juice, flavored drinks, or sodas.
• Choose low fat milk (1% or skim) after 4 years of age. (Whole milk from 1-2 years is okay for the normal weight toddler. 2% milk is okay for the normal weight 2-4 year old.  It is now acceptable for most kids to take in lesser milk fat than previously recommended.) 
• Limit portions on the plate to fist sized. Keep the serving platters off the table.
• Don't skip meals!
• Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks.
• Don't forget to move every day and get enough sleep!