Breastfeeding Round Two

If you've been a longtime reader, you know about my struggles to breastfeed Penny and my unwavering determination to fight back from low supply. If not, here are a couple posts that give the story:
Feeling Like a Failure
Small Miracle: Formula-Free!
Since that time, I have learned so much about breastfeeding. I have been involved in breastfeeding support groups and listserves. I have read lots of books and articles about breastfeeding. I know lots more about herbs, pumps, things that can boost or lower supply, etc, etc. And this time around, things are a lot different. This time, I was prepared to battle low supply. I hit the ground running, and being on the offensive has proven much more effective and less stressful than trying to fix problems that were already out of control. Here's what I've done this time around to attempt to make enough milk for Olive and to ensure the most positive breastfeeding relationship possible:

• Consulted with an IBCLC during pregnancy a couple of times. The first time was early on to talk about weaning my toddler and how that might impact supply for Olive. Her advice was to breastfeed as far into the pregnancy as possible, as the shorter the breastfeeding break, the more milk I would make the second time. I also talked to an IBCLC in the third trimester to get advice on how to get a good start this time around.
• Scheduled an IBCLC home visit when Olive was 3 days old. As much as I think I know about breastfeeding, this visit was critical. My insurance covers it 100% (based on the new affordable care act–thanks, Barack!), so check with yours if you're having a baby and planning to breastfeed. I believe that every mom should get an IBCLC within the first few days after birth to ensure that everything is off to a good start. It is much easier to prevent problems early on than to try to fix them once things are broken.
• Rented a hospital grade pump and started pumping from day one. This was also covered by insurance (after a huge headache described here), as required by the Affordable Care Act. There is a significant difference between personal pumps and hospital-grade pumps. If supply is any kind of an issue, a hospital grade pump is essential.
• Pumping after feeds as often as possible. Pumping after a feeding signals to the body that baby needs more milk and amps up milk production. It takes a few days to see a difference. I have been pumping about 4-5 times/day for 10-15 minutes. 
• Lots of water.
• Eating lots of galactagogues like oats, almond milk, and lactation cookies.
• Taking lactation herbs. I have used More Milk Plus and Lactation Support. The best prices I have found are on Amazon, but they also sell these at Whole Foods, health-food stores, lactation specialists' offices, and baby/breastfeeding boutiques/stores:
 
• Visualization–I didn't find any official programs for breastfeeding/supply (although I suggested to Circle & Bloom that they create something, and I think they are going to), but I have done some informal visualization exercises on my own. I picture milk being created and filling the breasts and try to relax and focus in on what needs to happen in the body for lactation. If nothing else, it is relaxing/calming, which is helpful for producing milk anyway.
• Mother's Milk Tea. This is more of the same herbs as above, but the tea is also soothing and warming and better for supply than coffee or alcohol.
• Domperidone. My midwife recommended going ahead and taking this right from the start. I had no adverse effects last time, and I have lots of the medication left over, so I started taking it on day 2 or 3. Ultimately, I decided I'd rather take it and make enough milk than not take it and possibly have to give formula.
• Skin-to-skin/close contact. I have hardly left Olive's side since her birth. I have shared her in little bits with grandparents and dad, but most of the time, she is snuggled near me or sleeping in her cradle inches from my bed. I have been wearing her in the ring sling, letting her lounge on me, or just carrying her. Close contact is hugely important in the breastfeeding relationship.
• Daily weight checks. When Penny was wee and having weight gain issues, we bought a baby scale. It cost about what the rental fee was for a couple of weeks. It's sensitive to the half ounce, so it's great for daily weight checks. It's not really sensitive enough to measure milk transfer in the baby, but it is so nice to be able to weigh the baby at home and know every day where she is in her growth. Weight gain is the number one measure of whether baby is getting enough milk. Here's the scale we bought:
• Switch nursing/breast compressions/distinct feeding sessions. Olive is a pretty sleepy baby. Penny was a sleepy nurser too, and I bet many babies tend to be this way. If left to her own devices, she would graze at the boob for a long time without really transferring much milk. The problem with this behavior is that she isn't being efficient. Her tummy never gets full. The breasts never get the chance to fill. And her weak/lazy latch just makes me sore rather than stimulating supply. I tend to think this was actually my biggest problem with Penny, and I never really understood it fully until last week when I met with the IBCLC, my midwife's assistant, and our family doctor, and they all emphasized this point to me. In order to combat this behavior, feeding times have to be defined, and Olive and I both need to be focused on the task at hand. Her job is to efficiently remove milk. My job is to keep her awake and alert. This is accomplished by using breast compressions, switch nursing (switching sides if she starts to get sleepy–I usually do 5 minutes on each side twice to add up to 20 minutes or so), taking her clothes off, massaging her back or head, changing a diaper in the middle of a feeding to rouse her more. Whatever it takes! A feeding for us should last about 20 minutes, should include equal-ish times at each breast, and should involve rigorous sucking with noticeable swallowing for most of the 20 minutes. After that point, if she still seems hungry, she gets a supplement and I pump. Of course there is a place for comfort nursing, but it shouldn't last all day, and in my case it doesn't help my supply as much as pumping does.
• Supplementing as needed: Rule # 1 is Feed the Baby. In the breastfeeding group I'm in, the moderator says there are 3 rules: #1 Feed the Baby, #2 Protect Your Supply, #3 Fix the Problem. If baby is hungry, she needs to eat. I have been lucky enough this time to have enough expressed milk to supplement with my own milk when we've suspected that Olive is still hungry after nursing, but I was prepared to give formula if I needed to. I would have preferred donor milk, but we didn't have much time to find a donor, and Josh wasn't entirely comfortable with that idea anyway. We bought some formula on day 3, but it is still sitting on the counter, unopened, with the receipt to return it if we don't need it. Since I have about 2-3 ounces of breastmilk in the fridge now, I think chances are good that we won't need the formula. In order to stockpile the expressed milk, I had to pump after feedings even when Olive seemed satiated. When she finishes a feed and seems full, it is likely that there is some milk leftover. By pumping after those feedings, I can get a bit extra to feed her at the times of day when my supply is lower. During these early days, a supplement for her is something tiny like 1/3 or 1/2 ounce. There is an art to figuring out how much supplement to give, as babies have tiny tummies, and giving too much can jeopardize supply. We supplement using a plastic syringe at the breast in order to avoid nipple confusion.
• Avoid or limit peppermint, spearmint, sage, oregano, parsley, thyme, alcohol, and caffeine. These can all negatively impact milk supply.

Wow, seeing all these things written out makes me realize how much power I have to impact my supply and how much work it is to start off on the right foot. Somehow, it feels much more doable this time around and less exhausting. We are still just taking it one day at a time though and continue to hope and pray that Olive continues to gain weight and seem happy and full.