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Caitlin Whyte: There is so much information out there about breastfeeding, especially in the age of social media. So in this episode, we are going to break down what we think are the best tips for breastfeeding parents with Chaka Davis, an assistant nurse manager at the Lactation Center in the Midlands, and Carla Wham, a newborn care coordinator at the Breastfeeding and Newborn Care Center.

This is Flourish, a podcast brought to you by Prisma Health. I'm Caitlin Whyte. So to start off our conversation today, Chaka, how soon after giving birth should a new mom try to breastfeed?

Chaka Davis: So great question, most full-term healthy babies are ready and eager to begin breastfeeding the first hour after birth. They show their parents they're ready to begin feeding by giving out hunger cues or feeding cues, such as eating their hands and smacking their lips. This is usually seen, again, within that first hour after birth and actually the American Academy of Pediatrics also recommends that babies be placed skin to skin on their mother right after birth. So this is when you have a naked baby who is skin to skin on their naked mother. This helps to keep babies warm. It helps to keep the baby's blood sugar up, and it also helps to get the babies ready to breastfeed for that first time.

Caitlin Whyte: Gotcha. One hour after birth. I didn't know it was that quick. So, in general, what are some of the benefits of breastfeeding, Chaka?

Chaka Davis: There are many benefits to breastfeeding for both mom and baby. Breast milk is produced by a woman's body specifically to meet the needs of her baby. So for example, a term baby has term breast milk made especially for him and a pre-term mother makes pre-term breast milk especially for her baby. Breast milk changes throughout the feeding and it changes over the course of the breastfeeding journey. The breast milk that was made for the one-week-old is going to be different than the breast milk that's made for the six-month-old. And if a mom is sick at any time during her breastfeeding journey, then she's going to begin producing antibodies to fight off that illness. And it actually is passed from the mother to the baby through the breast milk to help prevent her baby from getting sick or at least to keep that sickness to more of a mild illness. So these are all benefits to breastfeeding and providing breast milk for a baby.

Of course, there are also more talked about benefits to breastfeeding and breast milk, such as the improved dental health for the baby, decreased risk of ear infections, diarrhea, decreased sudden infant death syndrome and asthma, decreased risk of type 1 and 2 diabetes, leukemia and childhood obesity. You know, we often focus on the benefits of the baby and either overlook or gloss over the benefits to the mom, because moms are always more concerned about their baby and maybe less concerned about their own health. But moms can have a decrease in excessive blood loss after birth, decrease risk of breast cancer, ovarian cancer, and even thyroid cancers. She can have a decreased risk of hypertension, type 2 diabetes and even rheumatoid arthritis. And my favorite is not to mention that when a woman is breastfeeding or pumping her breast milk, we can burn extra calories just by making milk.

Caitlin Whyte: What a benefit. Oh, my gosh. Well, you know, Chaka, there are so many thoughts and opinions about breastfeeding out there. But are there any myths or misconceptions that you'd like to clear up here?

Chaka Davis: Well, there's a ton of myths and misconceptions and we could actually do a whole podcast around them.

Caitlin Whyte: Right. Oh, my gosh.

Chaka Davis: I'm actually just going to point out a few common ones. So one that we hear a lot here in the hospital is that women think they don't make milk in the first few days and that's actually not true. You can begin making colostrum or that first milk at about 16 weeks' gestation. And some moms actually begin leaking during pregnancy and some don't. So just because a mom doesn't leak doesn't mean that she's not making milk. So we actually recommend that babies are fed on demand, so anytime they're showing those cues that I spoke of earlier, and that will help a mom to increase her milk supply and help that milk to change from that thick, sticky colostrum that is very good, it's high in protein and carbohydrates, but it's low in volume and help to change to that more mature transitional milk.

Another misconception around breastfeeding and breast pumping is that many moms think that it's painful and that it should hurt, but it should not be painful and it should not hurt. Moms may feel some tugging, but they should not feel pinching, they should not feel biting or rubbing and they should not power through. If it doesn't feel comfortable, then something may not be right with the latch, something may not be right with the positioning of the baby. Even if it looks right on the outside, if they feel pain, then something's not right on the inside. So they really need to make sure that they follow up with a lactation consultant so that we can observe the feeding and help identify the problem and work towards finding a good solution.

Another misconception that can actually deter women from breastfeeding is they feel like they have to do a certain diet or avoid certain foods, and that's not true either. I would just say watch what you eat like you normally would watch what you eat. If you're sensitive to certain foods or you have allergies to certain foods, then naturally you would avoid those. Most other foods are okay in moderation. So a great example is caffeine. So if you have to have your coffee in the morning, have your coffee in the morning, or if you have to have a Coke for lunch, have a Coke for lunch, but just don't overdo it by having the Starbucks in the morning and then the Coke in the afternoon and then the tea at night for dinner. And then, definitely, if you find that your baby's becoming fussy and gassy, then you can start keeping a food diary to see if it's something you're eating or is it something else that's going on with your baby? So then, you'll need to contact your doctor or contact a lactation consultant to help you figure out what's going on and develop a plan.

And then lastly, another misconception is that many women will think that the size of their breasts will determine how much milk that she will make, and that's not true either. Women can breastfeed regardless of the size of their breasts or their nipples. They just may need a little help from a lactation consultant to find a position that works best for them or for their babies.

Caitlin Whyte: Well, let's get into some of those positions. What are the best ways to promote breastfeeding?

Chaka Davis: So any position where a mom and baby are comfortable and they have a comfortable latch is a good position for breastfeeding. In the first few days, mom and baby are getting adjusted to each other and they're learning how to breastfeed. So there are a few, I would say, that are like our go-to positions for breastfeeding that we use, especially right after delivery. So one of them is the biological nurturing position or laid back position. So this is where the mom may be in the bed. She's at more of a 45-degree angle. The baby is placed on her stomach skin to skin and gravity is helping to hold her baby on her stomach. The baby will then begin to smell and feel the way to her nipple. She may have to help adjust the latch. But typically, the baby will move his head back and forth, will open his mouth wide in line to latch on and begin to nurse.

Another kind of go-to position in the early days is a cross-cradle position. This position will help moms to have a good support of their baby because when they're first born, they're kind of floppy like a little doll. And so this will help her to have good support. So she'll just sit straight in a comfortable chair. She will bring the baby across in front of her body, again tummy to tummy and the baby will be facing mom and she'll hold the baby kind of in the crook of her arm, opposite of the breast that she's feeding, then support the back of the baby's neck, not the head, but the neck. And she'll actually be supporting the baby's body with her arm. Then with that free hand, she'll support her breast to help the baby to latch on.

And then lastly, a good position for our moms who have C-sections is a football or a clutch hold. So this is good also for moms who have large breasts. She'll control the baby beside her, again that baby's facing her tummy to tummy. So you can see I have a pattern here, tummy to tummy, babies are facing their food and then her elbows will be bent. And then, she'll have a free hand where she's going to support that baby's neck with the free hand. And then her other hand will support the baby's breast to help the baby to latch.

Caitlin Whyte: Now, Carla, what if my baby won't latch or doesn't seem to be able to get enough to eat?

Carla Wham: So if your baby won't latch in the first few days after it's born, the first thing I want to tell you is don't panic. You know, some babies just need a bit of time to learn how to breastfeed. And in those first couple of days, there's no urgency. Baby steps of learning will become more naturally if baby has kept skin to skin with mom and they can practice together. There's a learning time for both of them. It may be difficult, you know, in the beginning, but it definitely gets easier with time. I always like to say it's kind of a dance between moms and babies. And like Chaka said, you know, whatever position is comfortable for both, just making sure the baby has a good latch.

There are definitely some challenges with latching. Sometimes moms may have inverted nipples, flat nipples. When the milk comes in, the breast may be engorged or full, making it more difficult to latch. Poor positioning, amazing how just a few tweaks with positioning can make a huge difference in getting a baby to latch on. Nipple confusion, all of these are issues that we would want to assess or support moms with lactation support in the hospital. Other causes may be prematurity, illness, jaundice, tongue tie, cleft lip, torticollis, which will take maybe some longer support with lactation once mom leaves the hospital.

The most important thing, if baby's not latching, is that we assist moms in developing and maintaining a robust milk supply. And we can do that in the early days by doing hand expression and then maybe moving to some pumping as we need to. And the second thing is ensuring that babies are getting adequate nutrition. And then with support, we will bring the two together and work on a longstanding breastfeeding relationship.

Now, how do we know baby's getting enough? This is a common concern of most parents. We hear this question almost every day, you know, when you're breastfeeding and you don't actually see the volume of milk that the baby is taking. And in the early days with colostrum, babies are just taking very small amounts. And that's what it's meant to do. Babies' stomachs are very small. Colostrum is in small amounts. And then, as mom's milk comes in around 72 hours, then babies' stomachs are getting larger and they're able to take larger volumes.

So things that we're going to be looking forward to ensure that babies are getting that adequate volume are, again, looking at that latch, is baby swallowing at the breast? Did mom's milk come in, you know, at least by day five? Is mom's breast full? And then after feeding, do they soften? And then, we're going to look at the baby's output, how many times baby's feeding at the breast as well as weight. So when we look at output, we're going to really keep track of our wet and dirty diapers in those first few days. Day one, we want one wet diaper, one dirty diaper. And then day two, we're looking at two wet diapers, two dirty diapers. Day three, three wet, two to three poops. And then, by day five, we're looking for some yellow seedy poop.

So in the beginning, babies are trying to get rid of all that amniotic fluid that they have taken in when they're inside in utero. And it's kind of a sticky, dark stool. And then, by day five, we're looking for yellow seedy poop, which is your breast milk poop. After day six, we really want babies to have at least six wet diapers a day. All babies are going to lose a little bit of weight, it's normal. Our goal is going to be for them to be back to their birth weight by two weeks at least. Some are sooner, 10 to 14 days. Once mom's milk comes in, we expect them to start to gain weight about a half an ounce to an ounce a day or four to seven ounces for the week.

And then feeding frequency, you know, the first 24 hours, babies, we expect them to be a little sleepy. But then, they tend to wake up and they cluster feed and it's kind of their job. That's how they're really doing their job and stimulating mom's breast and bringing that milk supply in. We call it second night. They kind of wake up and realize, "Oh my gosh, I'm hungry," and do the cluster feeding. After that, we expect babies to eat at least eight times in 24 hours, but eight to twelve times is normal. Babies eat when they're hungry. They stop when they're full. Mom's milk volume changes throughout the day. Sometimes they take in more. Breast milk is easily digested. So when babies start showing those feeding cues or hunger cues, then we definitely want to feed the baby. What we don't want is a baby that's sleeping all the time, that doesn't wake for feedings or gets to the breast and falls asleep within a few minutes.

So if we're seeing an issue with output or weight or babies aren't eating or mom's breasts don't soften when the baby eats or mom's milk hasn't come in, all of these would be concerns that they would want to reach out for support and have an assessment with a lactation consultant, and I definitely encourage that. And they can do an assessment both on mom and baby. We can do weighted feeds, see what the baby's taking. And also make a plan, a feeding plan, so we can get a strong breastfeeding relationship established.

Caitlin Whyte: Absolutely. And Chaka, I'd love to focus on preemies for a second. And if they can't latch, how can we ensure that preemies receive breast milk until they can?

Chaka Davis: So if a baby is born premature and is unable to go to the breast, we want to ensure that they receive breast milk until they're able to latch and are able to go to the breast. So we encourage our moms to express their milk as soon as possible, just like we encourage our moms of healthy term babies to put their babies to the breast within that first hour. So with our moms who have a premature baby, or who has a sick baby who has to go to the NICU, we encourage them to express their breast milk within the first hour as well. And they can either do this via hand expression, which is using their hands to express that colostrum. And usually, with the hand expression, they're able to get more milk out than with the pump in those first few hours or days, because that colostrum is really thick. It's thick like a milkshake, is how I like to describe it, and it's trying to get milkshake through the straw. So if they use their hands, they can typically get more out than if they use a pump. But some moms would prefer to use the pump to pump their breasts, and that is perfectly fine. But we like to have them express their breasts at least eight times in 24 hours, similar to our babies who are able to go to the breast. So if they think about the fact that we want their babies when they're able to eat, to eat at least eight times in 24 hours, we need moms to stimulate their breasts at least eight times in 24 hours so that she can establish an adequate supply. And actually how often moms stimulate their breasts in these first two weeks will set the path for how adequate of a milk supply that she will have even two, three and six months down the road.

And we do have breast pumps in our hospitals. Oftentimes, moms will bring their own pumps and will, you know, like to use their own pumps. But breast pumps that we have in our hospitals are hospital grade and hospital strength pumps. And they're actually designed for when babies are not able to go to the breast or when babies are having difficulties latching, as Carla just described. And whenever moms are pumping their breasts and they're producing breast milk, then we're able to give that breast milk to their babies in the NICU as soon as the doctors say that it's okay for their babies to start eating.

Caitlin Whyte: Okay. So much incredible information. Thank you so much. Now on that, Chaka, feeding schedules and sleeping schedules are so, so important. Now, should I wake my baby to keep feeding on a schedule or if they're sleeping, just let them sleep?

Chaka Davis: So that's always a tricky question and, really, it depends on the baby. But a newborn baby should breastfeed eight to twelve times per 24 hours for at least the first month. And that's because breast milk is easily digested. So some newborns are often hungry and frequent breast feedings help to stimulate mom's milk production during those first few weeks. So by the time the baby is one to two months old, then they'll probably nurse just a little bit less, so about seven to nine times in 24 hours or a day.

So to answer your question, it will just depend. So if we look at those feedings and per 24 hours, we really want to make sure that they get all of those feeding in. So it really depends on when was the last time the baby ate and if the baby should be woken up or if it's okay to let them sleep. Because for that newborn, they shouldn't go any more than four hours without a feeding, even if it's overnight. But as they get older, they're going to set their own predictable schedule and then it will be okay to let them sleep.

Caitlin Whyte: And Carla, I'd love to talk about our working moms now. How can we keep milk supply up during the day after returning to work?

Carla Wham: Yeah. You know, a lot of moms, that is a major concern for them. So I just have just a few tips to point out. The first tip I'd give is before they even have the baby, going to their manager or their workplace and letting them know that when they return, they do plan to be pumping to provide breast milk or mother's milk for their baby. And one of the main things is to make sure that they have a proper location to do that. And most of the time, employers already have a lactation room or something available, but it's good to have that conversation before you leave on maternity leave, so you know what to expect when you return to work.

The second tip I always give moms is after you have your baby, that first part of your maternity leave, just enjoy your baby. Don't focus on going back to work or worrying about any of that. Just enjoy your baby, exclusively breastfeed. Between four and six weeks is kind of a magic window when we would want to start to introduce a bottle now and then. Sometimes before that, babies can have a bottle preference. If we continue to breastfeed until maternity leave is over, sometimes babies have a breast preference, and it's very difficult to introduce a bottle at that time. So around four weeks is a good opportunity for daddies to start to give a bottle now and then, and moms to maybe get their pump out, start to do some pumping. If they've collected breast milk in other ways, through like a Haakaa or another device, they can go ahead and introduce. Moms do need a little stash of breast milk in their freezer, I would say. They don't need a whole freezer full of breast milk prior to going back to work. But it is a comfort to them when they do go back to work to have some supply already built up so that they're not pumping today for tomorrow's milk.

About three weeks or prior or a month before going back to work, I would suggest to go ahead and start to do some pumping. Think about what the work schedule is. And if she's going to be working during the day, then after feeding during the day, she may want to go ahead and pump 15 minutes after feeding her baby, start to collect those little bits of milk. When she does return to work, she's going to want to express her milk about the same amount of times that she would be breastfeeding her baby at home. What this is going to do is give her that little bit of stash in her freezer, but it's also going to increase her milk supply slightly so that when she does go back to work and just the stress of that at times can decrease your milk supply a little bit, it just kind of evens that out.

And then another tip that I give moms when they're going back to work is when they do, if they could go back on a Thursday, that would give them a shorter work week. So they would focus on Thursday and Friday and have the weekend to recover before they're facing a Monday through Friday work week. Prior to that Thursday, they can go ahead and simulate what they'll be doing when they go to work like doing the pumping, having an alternate person give the baby a bottle and just seeing what challenges might arise with that. So this would be just a few of the tips that I would give to moms just to get ready.

And of course, you know, there are other situations with rotating shifts and different schedules with working 12-hour shifts and they can always reach out to a lactation consultant for support to make an individualized plan.

Caitlin Whyte: Well, that brings me right into my next question, how soon after giving birth are we able to call a lactation consultant for help?

Carla Wham: So all of our Prisma Health Hospital actually have lactation support and are available to all of our mothers in the hospital. We do try to see all of our breastfeeding mothers, but I would encourage them to call with any questions, if they need assistance with feedings, to identify anything that would be an ongoing challenge. Before our moms leave the hospital, we do give them resources. We have helpline warm lines so that moms can call when they leave the hospital. And we would rather them call sooner than later with any questions, concern, challenges, so that we can, you know, support them and just let them have a successful breastfeeding journey.

We do have availability for outpatient visits. When moms call a warm line, a lactation consultant will return that call, answer their questions and identify if there is a need for them to come in to be seen. A lactation consultant can then, you know, do an assessment on both the mom and the baby. We can do weighted feeds. We can see, you know, what the issues are and then set them up with a feeding plan to move forward.

One of the resources, or I've had the privilege of being involved in starting the Patewood Breastfeeding Center last April 2021. It's been a great resource, a tremendous resource in our Greenville area. In our first year, we were able to support over a thousand mothers, which I thought was successful. All of our lactation teams within Prisma Health are, you know, just a tremendous resource. And one of our mothers, she actually just wrote a letter and just was so grateful. This mom had had a difficult time with her first baby and she did not seek help. She ended up pumping exclusively for 12 months, which my hats off to her. But with the second baby, she truly wanted to breastfeed and she sought out lactation support early, and we were able to give her that support and continue to give her that support through the different challenges that arose. And, you know, , it's awesome to say that she is still breastfeeding at six months. And at the end of her letter, she said, you know, "The Prisma Health patients and Upstate community is lucky to have an amazing resource and team at the breastfeeding and newborn care center." And we have these amazing teams at all of our Prisma Health locations. I think we have outstanding lactation support. And she said, "I am confident my success with breastfeeding is largely due to their help and kindness regardless of a mother's goals around breastfeeding. The team is encouraging and supportive to ensure the best interest of both the mother and the baby." So I truly encourage moms to call and to call early.

Caitlin Whyte: Well, we love to hear those stories, Carla. As we get ready to wrap up our episode here, a few more questions. What recommendations do you have on storage of breast milk?

Carla Wham: So that's another thing mothers need to familiarize themselves with. Everywhere you look, you're gonna see different guidelines. So you can look at multiple resources online. And I think probably different lactation consultants are going to tell you a few different things as well what works well for them. I tend to be a little more conservative and make it easy for moms. I have the rule of four's. So four hours at room temperature, four days in your refrigerator, four months in the back of your refrigerator freezer. That's not in the door of your freezer. I also recommend that mom's date and time their breast milk so that they can rotate it and maybe place it in a Tupperware container, just so that it doesn't taste like the walls of the freezer. And when they go to use their frozen breast milk, they can definitely thaw it in the refrigerator, but it has to be used within 24 hours once it starts to thaw. When they take it out of the refrigerator and warm it for a feeding, they would want to warm it in a bowl of warm water. We definitely don't want to microwave breast milk or formula, just a bowl of warm water to bring it to room temperature. And then they would want to use that breast milk with that feeding.

Caitlin Whyte: And how long do moms typically breastfeed their babies? Is there an ideal timeframe you can give us?

Carla Wham: So the American Academy of Pediatrics just came out with a new update, and just in June of 2022, which was last month, and they do recommend and continue to recommend that babies receive exclusive breastfeeding or breast milk for that first six months, that it is not necessary to introduce formula or even complementary foods during that period of time for the normal healthy baby, of course.

And then after six months, You know, breast milk definitely changes with baby's needs. And there is nutritional value to breast milk after six months. But we do start to introduce some complementary nutritious foods during that period of time. They also state that there are benefits of breastfeeding, you know, of breast milk to both moms and babies now past a year, up to two years. And especially for the moms, they're pointing out that it does show that there is protection against diabetes, high blood pressure and cancer of the breast and the ovaries for moms.

Caitlin Whyte: Well, ladies, thank you so much for your time and doing this critical work, helping out new parents and their babies. For more information and other podcasts just like this one, head on over to prismahealth.org/flourish.

Carla Wham: This has been Flourish, a podcast brought to you by Prisma Health. I'm Caitlin Whyte. Stay well.