Michelle Hottya, IBCLC

Welcome back, ! It is so great to be back in the with my favorite team and my favorite people!

Moms will eventually co-sleep with their babies, even if it’s unintentional. We must educate ourselves on safe cosleeping practices. An armchair, recliner, sofa, etc. is NOT a place to sleep with your baby. The Lullaby Trust created this infographic with some helpful tips. You can also visit https://cosleeping.nd.edu for more helpful information on cosleeping.

Most babies, especially breastmilk fed babies under 6 months old, NEED to eat overnight. 😮

I KNOW how hard it is. I was a full-time working mom with all of my kids, and none of them were “good” sleepers👼. I would honestly have done anything to get a little more sleep at night. 😴

BUT… a 2015 study showed that 79% of babies 6-12 months old were still waking at least once overnight and 61% had at least one overnight feed.🤓

If babies were really supposed to be sleeping 12 hours by 12 weeks, they all would be. “Sleeping through the night” at this age should be the exception, not the rule. 🤱

There are tons of products and “programs” out there on the market right now that can actually cause babies to sleep through their hunger cues. Often (but not always) these babies are not making up the calories during the day. Around month 4, their weight gain drops or even slows entirely.😢

And honestly, a lot of babies just can’t sleep long stretches period, no matter what “method” you use.🤷‍♀️ There are babies who sleep long stretches and babies who don’t and neither of these is a bad baby. Everyone is different. Every baby is different.👩‍🍼

So what do you do? Instead of focusing on stretching out the time between feeds and trying to make a baby stop eating overnight, focus on getting yourself back to sleep as soon as possible when baby wakes up. 😴Two or three overnight feedings aren’t terrible if your baby goes right back to sleep (and so do you).

Read more here 👇🏼
https://www.rachelobrienibclc.com/blog/sleep-training-and-breastfeeding/ ❤️

(P.S. this is the reference for the study info above https://pubmed.ncbi.nlm.nih.gov/25973527/)✅

I wouldn't be the lactation consultant I am today without my wonderful friends, colleagues, students, and clients who journey with me in this profession! Happy IBCLC Day 2023!

If you have oversupply, maybe you don’t have a “slacker b**b!"

I see the term everywhere in parenting groups – “My left b**b is the slacker. It produces half of what the right does!”

If the parent is making more milk than their baby can eat, what if this isn’t actually a problem? Maybe the “slacker” is actually making the right amount and the other breast is an over-achiever!

If you are making just enough or less than your baby’s daily milk intake, this post is not for you. Let me know if there's a topic I can address!)

There are many reasons why the breasts may make different amounts of milk. I’d like to address a few here and show you why sometimes what is normal can worry us unnecessarily!

Sometimes babies prefer one breast because they are more comfortable lying on one side of their body, or the parent defaults to starting them on the same breast, or they nurse all night side-lying in one position. The breast that gets more attention, more effective feeding, may learn to produce more. Gradually the other diminishes in production due to less frequency of stimulation and less efficient emptying. It becomes a cycle.

Occasionally the breast size/shape/structure is related to differences in milk production. While it is totally normal to have asymmetrical breasts, they are often close enough to have balanced milk supply. If there is a drastic difference in breast dimensions, and it affects milk production, see an IBCLC!

For parents who nurse the baby and feel lopsided, check that you’re switching sides each feeding, offering both breasts each time and not favoring one. As a lactation consultant, I don’t recommend block feeding (that’s a whole other post!). I find that switching sides in the feeding gives the baby the most well-balanced diet and gives the breasts the chance to balance out production.

Pumping parents may notice that there is a slight difference in milk expression depending on the time of day or their stress/activity levels. Some parents find that they pump more milk over time, especially if pumping to “empty” pushes the demand for more production. Not everyone needs to pump to empty every time – I prefer to recommend pumping to “enough.” When there is oversupply, the breasts get ahead of the baby. Pumping for relief or to “empty” triggers more and more. The family ends up buying and filling a deep freezer to store all this *unnecessary* milk that the baby may never drink and ends up tossed. (Please don’t toss milk, donate it!)

Sometimes in these scenarios, one breast is driving the oversupply while the other is remaining normal. The normal breast is not a slacker! We need to teach the oversupplier to calm down. Slowly lowering the pumping amount to be closer to equal to the baby’s feeding amount can teach the breasts to work together and balance out the production, rather than constantly ramping up with more milk that will just go to the deep freeze rather than the baby.

When both breasts are making enough to meet baby’s needs for their age, then we stop pumping at the amount baby needs, rather than pumping for a certain length of time. I don’t mind when clients have a “comfortable abundance” – a little extra (1-2 oz more than the feeding amount) gives families a bit to chill for later without the risks of plugged ducts or mastitis of oversupply.

Reframing the concept of the “slacker b**b” helps families to feel more comfortable with what’s normal, rather than thinking their breast is falling behind!

Pay attention to compensations

I think a lot of people misunderstand how tongue tie causes problems when it comes to breastfeeding. Can tongue tie directly cause issues like air ingestion that leads to reflux? Definitely (there are 7 papers that show this).

But many other symptoms aren’t caused by tongue tie directly. Instead, the symptoms are a downstream problem caused by the baby’s compensation to the tongue tie. So if mom is experiencing significant ni**le pain, it’s not technically the tongue tie causing the pain. Because the baby uses the jaw/gums/lips to hold on instead of the tongue (when they’re tied), the latch is invariably shallow. That’s the source of the pain.

If mom needs a ni**le shield to help baby latch on or to avoid severe pain, that’s totally cool. Is it a solution? No. It’s a compensation and should be used temporarily until the reason that shield use is needed is determined.

If you’re supplementing with a bottle or SNS because nursing isn’t going well, that’s awesome. But that’s a compensation you’re making on the baby’s behalf if your goal is to breastfeed exclusively.

If you’re a lactation consultant evaluating the symptoms, don’t just explain them away. Don’t give the baby credit for “deciding” on doing things that are just instinctive on their part. Try to figure out the source of the compensation that’s causing the problems. Poor hold, poor latch, muscle tension, tongue tie, lip tie etc - these can all cause different compensations. The secret to improving the dyad’s symptoms is sleuthing your way through the problems.

Babies are born with a pretty primal brain - designed simply to keep them safe. The rest develops as they grow. This means that they will protest if they think they might be in danger, and their brain is designed in such a way that they feel safest on an adult chest. Its really logical - leave your baby somewhere cold and open and his brain thinks a wolf might eat him. The brain isn't evolved to understand that we have warm homes and safe cots. Babies feel safe when held. They aren't controlling you, wrapping you around their finger, or getting into bad habits. They are seeking safety in your arms.

😅
Maybe a few years, just to be safe.

“Fat increases in human milk with every mouthful baby gets.”

Continuing the posts from the past few days about the fat in human milk.

Why does fat gradually increase in breast milk? Because of the shape of the cell-to-fat connection.

The milk-making cell,or lactocyte, has a cell membrane like other cell membranes, which means it is rich in lipids. The lipids in human milk are in a globule encased in a membrane called, appropriately, the milk fat globule membrane, a complex and unique structure that needs its own post.

So we have a cell membrane that is lipophilic and a lipid secretion in the milk which is near that cell membrane. When the alveoli, which is a grape-like structure made of lactocytes, s full of milk, the lactocytes flatten which gives a bunch of surface area for the cell membrane and fat to connect. Because the fat is securely attached over a large area, a full alveoli does not have much fat. I’ve tried to show that in my upper drawing.

As the alveoli empties (my lower drawing) the shape of the lactocyte becomes more square since the cell isn’t squished by milk. The cell membrane has less area to connect with the fat, the fat cell is not connected as much and fat enters the milk more easily. Since the changes in the cell happen gradually, the loss of connection between cell membrane and fat happens gradually, and fat enters breast milk during a feed gradually.

This gradual delivery of fat during a feeding makes terms like “foremilk” and “hindmilk” frustrating to me. I’ve been asked “how long do I need to feed before I get to the hindmilk?” a bunch over the years, so this drawing comes from my attempts to explain that the fat will show up gradually. Fat increases in human milk with every mouthful the baby gets.

This is one of the reasons why oversupply makes babies miserable!

This is why I want everyone to STOP using the terms FOREMILK/HINDMILK.

SINGLE SIDE AND BLOCK FEEDING ARE NOT GOOD LONG TERM PRACTICES.

It's confusing and misleading. Parents are struggling with oversupply, low supply and fussy babies because of this.

Reclined latching, limited pumping and feeding BOTH sides every time are better for controlling supply and latch!

This is a photo of the cells that make up alveoli of the mammary gland. Fat cells are stained black. The white in the center of the circular alveoli is milk. I talk about it on my website in more detail here: http://www.drjen4kids.com/breastfeeding/oversupply.htm

The photo helps to illustrate why “foremilk” and “hindmilk” are unhelpful terms. And it’s a useful illustration for why breast massage or the use of vibration (I recommend a vibrating kid’s toothbrush) can increase the fat content of breastmilk.

The amount of fat in the milk varies with the amount of milk in the breast: a full breast has less fat and a less full breast has a higher fat content. This has a lot to do with the resistance of fat to being removed from the breast.

The fat cells hang on to the walls of the alveoli and it takes more energy to move them from that spot when the alveoli is full of milk compared to the energy needed when there is less milk being made. When the alveoli is not as full of milk, the fat is easier to remove.

So, when we start to remove milk, the alveoli first releases milk with a lower fat content, and as milk is removed, more fat enters. We have a higher milk volume in the morning, which then is lower in fat, and a lower milk volume at night, which therefore has more fat. This often leads to discussions of "foremilk" and "hindmilk"- unhelpful terms that are used to describe lower fat milk and higher fat milk respectively. The use of those terms makes it seem as if there are two types of milk (low fat and and high fat) and as if there is a point at which we switch from one type to another. Neither is true. If you look at the picture, there are some alveoli full of milk with no fat in the center and others that are completely collapsed and full of fat. The picture demonstrates nicely that the fat content is not all -or -nothing. The increase in fat is gradual over the course of the feeding. “Foremilk” and “hindmilk” are terms that lead to confusion about lactose concentration as well. (yesterday’s post).

Dr. Jane Morton, working with premature infants, showed that vibration and hand expression could increase both milk volume and calories in the milk better than pumping alone. In babies struggling because of maternal oversupply, I suggest vibration to help remove fat earlier than it would be released. More suggestions here: http://www.drjen4kids.com/breastfeeding/oversupply.htm

Don't ever compare your milk stash to anyone else's. That way lies madness.

I have a great blog over how to start pumping and build a milk stash while breastfeeding. You should check it out on my website under blog!

Link below! 🔗

https://www.rachelobrienibclc.com/blog/how-to-start-pumping-and-build-a-milk-stash/

World Breastfeeding Week is celebrated every year across the world from August 1 — August 7. This global campaign aims to raise awareness about breastfeeding and its advantages. Following a surge in the infant mortality rate due to a drop in the number of mothers who wanted to breastfeed, the initiative became essential. While everyone has the right to make their own decisions, breastfeeding is recommended by the World Health Organization (WHO) until a child turns two. This World Breastfeeding Week, let’s join hands and promote breastfeeding.

# bravebrelfie

When flushing is inevitable.

There are so, many, moments of tragedy and horror in first trimester birth. Giving birth in a bathroom. Not knowing when it will happen. Every trip to the toilet, wondering if this is the time. Peering into a bowl of crimson, studying the impossible red. Scooping pieces of young placenta out of the cool water, pieces so slippery. Pulling them gently, these pieces, to see if the tiniest person might be just underneath. Feeling unsure if you found any semblance of your baby, you pull the lever. Walking away, wondering if you missed it. Wondering, not just why your baby died, but wondering, where your baby is. Wondering, if you do find the physical form of your baby, what you will even do. What are the laws about this thing? What are my choices? Yes, your baby is real - but, just how real? What is expected of you? What will you do?

And, finally, there can be ENORMOUS shame when flushing is inevitable.

Many, many mothers have found vindication, peace and healing by speaking directly into this shame, by *deliberately* including water into their farewell.

From cutting a small piece of gift tissue paper, in the color that you choose, and writing a simple message on it, and flushing it - symbolizing reaching your baby -

To breaking flower petals at a shoreline, or, writing a Love Letter and sending it floating down a stream, you can send the message that your love can connect with your baby, and, that you are worthy. You are worthy. You are worthy to mourn, to find healing, to mother.

Join our Virtual Latch Event!

Covid is still here (I just had it), so I restocked these face masks in my Etsy shop. Link in the comments.

Does this mask make me look perky? I'm in my office today, happy to see clients in-person or by video consult. Both options are available for you!

THE PROMISE OF FREE LACTATION COVERAGE

“Isn’t lactation covered by my health insurance because it is preventative care?”

I have seen this question come up a lot among my clients and colleagues over the years and I want to shed a little light on it that healthcare consumers may not know.

YOUR INSURANCE COMPANY HAS WAYS TO GET OUT OF PAYING FOR YOUR LACTATION VISIT.

Let me repeat that: YOUR insurance company has ways to get out of paying for YOUR lactation care.

“They told me it was covered 100%.” They only cover a PORTION at 100%, the rest of the visit fee may be assigned cost-sharing with the patient (you).

“I thought it was guaranteed by the Affordable Care Act (ACA).” Most insurance companies have developed workarounds to limit how much they pay under the ACA rule. The organization that manages billing codes for the U.S. healthcare system has created ONE lactation code – a CLASS code. This means the insurance companies can assign payment under this code at patient education rates. Payments to IBCLCs vary from $9-71, no matter if they spent 30 minutes or 2 hours with you. Any other medical billing codes that are relevant to your situation may not be coded in their system to apply to this provision of the ACA.

Surprised by a bill from your IBCLC? We have to send those because the contract we sign to be in-network providers requires us to collect the portion they determine is your responsibility. WE didn’t say it’s your responsibility – your insurance company did.

“Why can’t you use different codes to help me get it covered?” As healthcare providers, we code based on a combination of factors: what the insurers allow for our credential; the time spent on your visit; the location of your visit; the medical conditions affecting your situation, etc. One insurance company tells their subscribers to tell us to use a certain code that is sure to get denied because our credential doesn’t qualify to use that code. Another insurance company promises to pay 100% and then reimburses us $9 for the code they told the subscriber. Earn $9 for a 1.5 hour visit and anyone will go out of business.

“Why do you bill for both mom and baby? My insurance paid on me but wants to charge me for the baby.” Lactation consultations usually involve two patients (or three with twins). Mom has her own health history, medical conditions, and treatment needs that are different from the baby’s health history, medical conditions and treatment needs. It is very rare that everything is PERFECT with one and the whole entire problem is with the other. Occasionally we will see mom only for a pumping visit or infant loss. Most of the time, we are helping both mom and baby to coordinate improved feeding.

“Lactation appointments are so expensive!” The cost of doing business is expensive. In the office, we have the costs of running a brick-and-mortar business. Doing home visits, we have the expense of driving all day, sometimes 50 miles between client homes (and OMG the price of gas right now is killing home visitors). We have the expenses of our supplies, our specialized scales and pumps, liability insurance, taxes, phone/computer/EHR, fax services (yes, medical offices still uses fax due to HIPAA restrictions on electronic transmissions), etc. And that’s BEFORE payroll. We charge what we need to keep our business running so we can help families like YOU.

“So how do we get covered?” Please pay your invoice and then send the receipt to your insurance company with a strongly worded letter of appeal to demand they reimburse you under the provisions of the ACA. Insist that they cover ALL codes submitted by the IBCLC under a lactation “umbrella.” If they refuse, appeal up the chain of command, contact the State Insurance Commissioner and file a complaint, or contact an attorney.

The alternatives? We stop taking insurance and you pay the fees out of pocket. Lots of medical providers are doing this.

“I have AHCCCS/Marketplace insurance – they said they cover lactation visits.” They do, under VERY limited conditions. The State of Arizona and WIC have an exclusive contract for lactation support. THEY WILL NOT PAY PRIVATE PRACTICE IBCLCS. They won’t, they just won’t, even if they told you they will. They won’t. WIC is contracted at the state level. You can get help from a local WIC office, or pay a private IBCLC. Most lactation consultants will offer reduced fee services to families enrolled in WIC. Don’t have WIC because you make too much but you have marketplace insurance? Call a private practice IBCLC and work out a payment plan. When it comes down to it, the insurance will NOT pay even if they told you they would.

“I saw another lactation consultant and the insurance paid in full.” Chances are they had either: a.) another credential (like RN) that provided additional coverage; b.) they had a biller file a successful appeal on your behalf; or c.) they accepted being underpaid. Usually it’s c.

We need YOU, the consumer, to advocate with your insurance companies for full coverage. We as IBCLCs have fought from our side and each year the insurance companies rewrite their codes to decrease reimbursements. To remain in-network, we are forced to agree to reimbursement discounts, and then they take more codes away from us to reduce payments more and divert responsibility to you. Some IBCLCs have additional credentials, so they may get reimbursed differently according to their contract terms. But please know we want your bill to be paid 100% by the insurance – it’s just that if they don’t, our hands are tied.

If nobody else is going to be honest with you, I will.

I don't want you to feel like the reality of life with a newborn slammed you like a wrecking ball!

To get a head start on what to expect, check out my blog "8 truths you NEED to know before your baby is born." https://www.rachelobrienibclc.com/blog/8-truths-you-need-to-know-before-your-baby-is-born/

Baby has trouble latching but you're doing everything you were taught?

This is the difference between the C hold and the U hold for making a sandwich with the breast for a deep latch in cross-cradle. To do the U hold and compress your breast in line with baby's mouth, drop your shoulder and elbow, then cup your palm around the bottom of your breast with your fingers parallel to baby's mouth.

"It worked for me" 🚩
"We turned out fine" 🚩
"I heard/read/was told" 🚩
"Here's a blog link from G00gle" 🚩

Please stop, think, and refer when you are about to give infant feeding advice!

Peer support sounds like:
"I know this is tough! Here are some resources."
"Can I run an errand for you?"
"Can I watch the kids for you while you deal with this?"
"Here's the number of my IBCLC."
"You're an amazing mom and I am proud of you!"

Babywise/Taking Cara Babies/The EASY Method/Ferber

GARBAGE. I see so many babies falling off the growth chart, moms losing milk supply, breastfeeding sabotaged by so-called "sleep experts." These are not compatible with normal newborn breastfeeding.

Let's figure this out for you better.

Formula shortage options:
-Order online for shipping. Plenty of inventory is in warehouses, because the supply chain is taking a long time to get to local stockrooms.
-Similac’s website has a search tool for local availability.
- Liquid, ready-to-feed was not recalled and is more available in some areas.
-Buy what you need, but STOP HOARDING EXTRA. Remember the toilet paper panic buying debacle? The supply chain will catch up if people stop buying more than they need.
- Donor milk - if you have a freezer full, calculate what you need and offer the rest. Post on your community Eats on Feets, Human Milk 4 Human Babies, or Buy Nothing groups.
- Oversupply moms - you can help your friends and family but don’t cause yourself new feeding issues by going crazy with more pumping.
-I don’t recommend homemade formulas. They are complicated and not reliably safe for your baby.
- To the grandmas and aunts: your recipe for evap milk + karo syrup gave several generations diabetes and heart disease, so it’s not the most helpful thing right now. If you want to help, order formula online to be shipped to your grandbaby’s house.
- Goat’s milk is not a 1-to-1 substitute for breastmilk or formula. The sodium content is too much for infant’s kidneys.
- Relactation can be done but it takes time.
- The most important thing is FEED THE BABY whether it is breastmilk, a friend’s breastmilk, or whatever brand of formula you can find. This is not the time to be picky about formula brands. They are all basically the same nutritional content. Generic is the same as brand names.

Helpful chart for those who use formula!

Many of my clients use these products while they are workng on building supply. When donor milk is not in the house, and milk production is not yet at baby’s needs, formula is necessary. I do not recommend homemade formula - too expensive, time consuming to make, and quality control is difficult.