My job is not just about milk
Some women are eager to maximize their milk production, others don’t want to make a project out of it. I’ll always remind her that she isn’t a milk dispenser, she’s a mother.
“My baby isn’t gaining enough weight.”
Many of my consults start this way. But even with the same starting point, these visits can go in so many different directions, because so many factors are involved. Physical issues can come from the mother’s side or the baby’s, and there are always personal and family dynamics to consider. It’s never just about milk.
Always, much of my time is in conversation with the parents. First, is the weight gain really too low, or is this a healthy baby who happens to be on the slow end of normal? Are the right growth charts being used? Many pediatricians’ offices are still using older growth charts, which were not based on breastfed babies. And any charts are just averages. Outside of Lake Wobegone, we can’t all be above average.
I need to know also whether the baby is at the breast often enough and long enough. If you aren’t in the restaurant, you don’t get a meal. Rigid schedules from books are one problem, but aren’t the only concern – one mother described to me how she tried every possible comforting technique when her baby cried, and only if she was still crying did she feed her. Of course sometimes the baby would run out of energy before this point, so she would give up and go to sleep, missing a feeding she needed. The mom was very health conscious, and conscientious, and had no idea she was underfeeding her baby. She came from a family where overeating, and associated health problems, were common. As a child, she felt she had been encouraged to eat for comfort, and eat past the point of satisfaction, and wanted to make sure she didn’t feed her daughter unless she was truly hungry. She was reassured when we discussed how feeding on cue would actually help her daughter learn to feel full and regulate her own eating. “When in doubt, whip it out!” was my advice. It was well received, but wouldn’t have found it’s mark if we hadn’t had the whole conversation.
Sometimes there’s a medical issue that needs attention, and it can be with either mother or baby, or both. Often the mother who calls me is already assuming the problem is on her end, saying “My milk supply is low.” Which it may well be, but lactation works by supply and demand. So a baby who doesn’t drain the breast leads to a mom producing less milk. If nobody’s ordering, the chef stops cooking.
I check inside the baby’s mouth, feel his sucking pattern, and watch the way he moves his head. A tongue tie – when the tongue can’t move normally because of the way it’s attached to the floor of the mouth – may be preventing the baby from nursing efficiently. Sometimes a difficult birth or awkward position in utero has left the baby with tension in the neck and jaw that makes breastfeeding difficult. Some babies, often those born a little early, have a weak or uncoordinated suck. I may wind up referring a baby to a specialist, and teaching the parents some suck-training exercises, and feeding techniques to help compensate.
Occasionally the mother’s medical history or breast exam gives me a clue that something is off in the “kitchen.” In these cases, I’m especially glad she is pursuing help. Low milk production can be a sign of a medical condition, like low thyroid; if she just stopped breastfeeding and left it at that, a chronic problem might go undetected for years, putting her at a greater risk for long term health issues. In those cases, I’ll be referring to a physician to treat the medical issue, while working with the mother on rebuilding her milk supply, and a feeding plan to help the baby get enough nutrition meanwhile. There are a lot of ways to approach supplementing, and it’s more important that the plan be sustainable than that it be perfect.
With a few mothers, I’ll have to bring up a tough subject: insufficient glandular tissue (IGT). This is when the mammary tissue did not develop fully, and can’t make enough milk as a result. This is hard news to give. The mother is likely to feel terribly disappointed, but she may also be relieved to have an answer. What I want to focus on with her is that she still has options. She might decide to give supplemental feedings at the breast. She might be interested in using donated human milk for supplemental feedings. Her milk supply may never be full, but there are ways to increase it if she wants to try. Some women are eager to maximize their milk production, others don’t want to make a project out of it. I’ll always remind her that she isn’t a milk dispenser, she’s a mother, and mention the saying “Love is not measured in ounces.” Her breastfeeding experience will be different from what she expected, but it can be rewarding, and it will be all hers.
Not long ago, mothers with slow-gaining babies would probably have switched to formula feeding immediately, end of story. Now, more often they want to figure this out. I’m glad of that, and not only for the sake of mother and baby’s health. I hear the sadness in the stories older women tell me at parties all the time: “I really wanted to breastfeed, but my milk wasn’t enough.” They were never offered the chance to get a real evaluation, which could have solved the problem, or at least offered an explanation for why breastfeeding didn’t work. However the lactation turns out, I want my client to eventually look back on her breastfeeding experience with pride in herself – not because she did or did not lactate, but because she faced a difficult situation early in mothering, took charge, persisted, adapted, and ultimately fed her baby in whatever way she decided was best.
I love my work, because it’s not just about milk.
© Jessica Lang Kosa Ph.D, IBCLC 2012