We all know what it takes to support a milk supply and help a baby grow. When creating a care plan for families, we follow the sage advice from the pioneers of the profession, such as Barbara Wilson-Clay and Kay Hoover in their book the Breastfeeding Atlas:
- Feed the baby – ideally with human milk
- Protect the milk supply with expression
- Preserve the breast focus
- Fix the problem (my addition)
Rigid, structured “triple feeding” is exhausting for parents and is unsustainable for very long.
When a baby is having difficulty with weight gain or is born prematurely, many clinicians will suggest that a parent feed the baby every two hours, supplement the baby with X number of ounces at every feed and pump every two to three hours. While the evidence to support the individual points of this care plan are well documented, my question is, “when does this end”? A better question is “why start with such rigid recommendations”?
I work in both an in-patient and outpatient setting. Occasionally, I am the last resort for families who are exhausted, sad, angry and want to stop breastfeeding or any work towards providing breastmilk. I hear their frustration. I believe there is a better way to provide competent care and empower them to do what is right for their family.
First, the suggestion to feed every two to three hours does not take into account the circadian rhythms of the baby. In the first few weeks, many babies are nocturnal, and prefer more frequent contact and feeding at night. A rigid schedule does not consider the times when a baby may be hungry or tired or overstimulated. A baby who is ready for a feeding will be more efficient than one who is told when they are “supposed to” feed. Teach parents about baby behaviors, including feeding cues, that will help parents decode their baby’s signals and empower them to be responsive to their baby.
Second, the recommendation to feed a baby X number of ounces at every feeding is to help a baby grow, our number one priority. While this recommendation may be to ensure baby receives enough calories throughout the day, it does not allow for the rhythm of the baby’s hunger. Granted, there are times a compromised baby is not obtaining enough calories and we need to temporarily override a baby’s lack of desire to feed. While unusual, this situation is important to address. Providing families with the goal of a total number of ounces per 24 hours is a more empowering suggestion. For a majority of families, the baby and parent can decide when and how many additional ounces at each individual feeding. They can gauge when the baby seems more or less hungry and adjust the volumes accordingly. Some babies who are directly breastfeeding will consume more milk early in the morning or in the middle of the night and do not require supplementation. The parents can reserve that milk and provide a bit more later in the day if the baby appears hungrier. Providing a goal of X number of ounces per 24 hours can also help families who may be unintentionally overfeeding their baby find a more reasonable volume for appropriate growth.
The third recommendation to pump 20-30 minutes, every two to three hours, is untenable. While this schedule may work initially, keep in mind all the steps involved:
- Find a good, private location to be comfortable and set up the pump
- Wash hands
- Gather all the pieces for the pump and put it together
- Adjust vacuum/speed. This may need to be adjusted several times during a session
- Implement techniques to elicit multiple milk ejection reflexes (MER), such as:
- Massage (hands, baby brush)
- Warm compresses (re-heating as needed)
- Auditory stimulus (music or the baby’s cry)
- Visual stimulus (pictures of baby or relaxing scenes)
- Olfactory stimulus (smelling baby’s clothes or blanket)
- Once pumping has ended, transfer milk into appropriate storage containers
- Label milk
- Wash pump parts
How long do you think it takes to do each of these steps? Many of my clients report it can take anywhere from 30-45 minutes, EACH session. They have 75 minutes between pumping to care for themselves (shower, eat, sleep) or attend to family needs.
A more reasonable recommendation is to pump 6-8 times in 24 hours, including once at night, for those who are exclusively pumping. While this may appear to be the same suggestion, it empowers parents and provides them with more control over the exact timing of the milk expression sessions. Many find it more effective to pump more frequently during the day/waking hours and allow for a longer sleep stretch at night.
Fixing the problem can be quite complex. It usually includes a way to supplement the baby to provide the least interference to breastfeeding. The recommendation should consider the parent’s desires and capacity to supplement in that manner for days or weeks. Supplementing at the breast with a tube, syringe or supplemental device is what many clinicians recommend because it provides stimulation to the breast and helps the baby to equate the breast with nurturing and nutrition. Cleaning these devices may take a bit more time than a bottle because of the size of the tubing, etc. Parents need to know if there are special tools to keep everything clean. Plus, these devices may need to be replaced frequently. Is there a convenient and affordable way for parents to obtain replacement parts? The solution for “how to” supplement the baby is to empower the parents to decide what method is best for them. A shared decision-making model provides the parents with the pros and cons of different methods. It allows them to pick and choose what method will work during different times of the day and the flexibility if they choose to go out with the baby.
Follow-up is crucial. Providing the family with several opportunities for evaluating and modifying the care plan is important to increase the duration of breastfeeding. Discharging a family without appropriate support is a disservice to the family. Refer them to resources in the community for support, weight checks, and to providers who are covered by insurance.
Provide families reasonable recommendations. Many families are relieved and grateful to gain more control over their lives when the burden of a rigid structure is lifted. Empower them to meet their breastfeeding goals. Learning more about how to be responsive to their baby will aid their self-efficacy as parents. Parenting is a marathon, not a sprint! Giving them the tools to succeed will have long-lasting effects!
Wilson-Clay B & Hoover K. The Breastfeeding Atlas. 6th ed. Manchaca, TX: LactNews Press, 2017, p115.
Baby Behaviors from the California WIC Association, in collaboration with UC Davis Human Lactation Center. https://www.cdph.ca.gov/Programs/CFH/DWICSN/CDPH%20Document%20Library/Families/FeedingMyBaby/970027-Getting-To-Know.pdf
Campbell SH, et al. Core Curriculum for Interdisciplinary Lactation Care, 4th ed. Burlington, MA: Jones and Bartlett, 2019, pp. 427-437.
Stanford Medicine. Maximizing Milk Production with Hands-on Pumping. https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html