Working & Breastfeeding Made Simple · Every breastfeeding added = 3-4 oz/90-120 mL MORE milk...

Working & Breastfeeding Made Simple

©2016 Nancy Mohrbacher, IBCLC,

FILCA 1

Working and Breastfeeding

Made Simple

Nancy Mohrbacher,

IBCLC, FILCA

~

I earn royalties from

sales of breastfeeding apps & books

I accept no funds from violators of the

International Code of Marketing of Breast-milk

Substitutes

~

~I receive speaker fees

for talks like this

Disclosure:

CHICAGO

Windy City?

• Planning during

pregnancy

• Maternity leave

• Milk norms

• Breast & bottle

differences

• Meeting

long-term goals

• Troubleshooting

Overview



FILCA 2

Planning

During

Pregnancy

Where to Start

• Ask coworkers: “Has anyone breastfed while working here?”

• Ask HR if a lactation program exists

Consider Work Schedule Flexibility

� Part-time

� Job-sharing

� Flex-time

� Phase back part- to full-time

� Compressed work week (same hours, fewer days)

� Work from home, telecommute

� On-site day care,

bring baby to work

Doesn’t have to

be all or nothing

• Creative use of vacation, sick days

• Privacy screen in manager’s office

Employer Solutions

http://www.womenshealth.gov/breastfeeding/employer-solutions/index.php

Options & Resources

Maternity

Leave

Know the Law

Legal requirements

to receive paid maternity leave

If no paid maternity

leave, what must your employer

provide by law?



FILCA 3

Return to Work by Baby’s Age

≤5 wk Cluster feeding common, fussy times, milk ramping up, ~8-10 milk removals per dayfor full supply, recovering from childbirth

6 wk to 3 mo

Milk supply at max, peak fussy times, average of 4 childbirth-related symptoms

4-5 mo Fussy times subside, if back to work now, more likely to breastfeed longer

6-8 mo Solid foods started, baby begins to need less milk

9-11 mo More solids, less milk, can transition to cup

≥1 year Most stop pumping at work, leave other milks/drinks for baby, breastfeed at home

Baby Arrives: Milk Norms

Knowing how

breastfeeding works

simplifies life

Clarifies what needs

attention &

what can be ignored

1st 40 days,

milk ↑quickly

• Day 1: 1 oz/30 mL

• 5 wk: 25-35 oz/

750-1050 mL

Milk removal

is main driver

of supply

A breastfed baby’s milk intake:

↑Increases from

Birth to Week 5 Hill, et al. J Hum Lact 2005;

21(1):22-30

↔ Plateaus til 6 mo

↓Decreases when other

foods started

Peak milk intake averages ~25-35 oz/750-1050 mL per day

From 1 to 6 mo breastfed babies

need ~same amount of milk per day

Because babies’ growth rate slows

Nielsen, et al. Pediatrics 2011; 128(4):e907-14



FILCA 4

Understanding Milk Production

Puts Mothers in Control of Their Experience

Know 2 Key Dynamics

Drained breasts make milk faster

Full breasts make milk slower

(FIL + pressure)

#1 Degree of Breast Fullness

Daly, et al. Exp Physiol 1996; 81:861-75

Language of Milk RemovalsOn average,

babies take ~2/3 of the

milk

available

To increase

supply,

babies take more milk

more oftenKent, et al. JOGNN 2012;

41: 114-21

#2 Breast Storage Capacity

Based on

volume of milk in

the breasts

at their fullest time

of the day

Not about breast size

Affects # milk removals per day needed to build & maintain supply

Daly, et al. Exp

Physiol 1993;78:209-20

Newborns’

tummies are small, so

Storage Capacity

may not be obvious till after

1st month

Photo: Nils Bergman, MD, MPH, PhD

Bergman. Acta Paediatr 2013; 102(8):773-77

Takes more time for breasts to

get so full that milk-making slows

May not need to remove milk often (or at all)

at work to maintain supply

Large Capacity



FILCA 5

Takes less time for breasts to get so full that

milk-making slows

Must remove milk

more often to maintain supply

Small CapacitySimilar to…

Concept: Jeanette Panchula, BSW, RN, PHN, IBCLC

# Milk Removalsper Day Needed to:

Largest

Capacity

Large

Capacity

Medium

Capacity

Small

Capacity

Smallest

Capacity

Increase milk 4-5 6-8 8-10 10-11 ≥12

Maintain milk 3-4 5 6 7 8

Decrease milk 2 3 4-5 6 7

Clues to Storage Capacity

Largest

Capacity

Large

Capacity

Medium

Capacity

Small

Capacity

Smallest

Capacity

Max pump yield

10-12 oz300-360 mL

5-9 oz150-270 mL

3-5 oz90-150 mL

2-3 oz50-90 mL

1-2 oz30-60 mL

Max longest stretch

10-12 hr 8-10 hr 7-8 hr 6-7 hr 4-5 hr

Good idea to wait 3-4 wk before

introducing bottle

Pump to comfort

as needed

Top priority: getting in sync with baby

Milk Expression During

Maternity Leave

Oversupply pros:

• Extra milk to store

Oversupply cons:

• Flow struggles

• Breast fullness

• Need to express

• Risk of mastitis

To Build a

Work Freezer Stash

Start storing ~3-4 wkbefore return to work

At work, milk pumped can be fed next day

Pump 1x/day = milk for

first day + reserve



FILCA 6

Pumping Averages

Baby’s Age Average If Pump

Replaces Feed

Average If Pump After or Between Feeds

First week

(after Day 4)

1-2 oz30-60 mL

0.5-1 oz15-30 mL

2-3 weeks 2-3 oz60-90 mL

1-1.5 oz30-45 mL

1-6 months 3-5 oz90-150 mL

1.5-2.5 oz45-75 mL

http://www.nancymohrbacher.com/blog/2012/11/27/how-much-milk-should-you-expect-to-pump.html

Kent, et al. Pediatrics 2006; 117(3):e387-95

Hands-On Pumping (HOP)http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

Increase in Milk Yield

>48%Morton, et al.

J Perinatol 2009; 29(11), 757-764

Milk-fat content

nearly double the averageMorton, et al.

J Perinatol 2012;Jan 5; 1-6

Image: Jane Morton’s DVD: Making Enough Milk

Available from www.breastmilksolutions.com

Hands-On Pumping

1. Massage both breasts

2. Double pump

3. Stop pumping &

repeat massage

4. Single pump or hand express

5. Alternate right to left

to right, etc. until milk flow slows

http://www.nancymohrbacher.com/blog/2012/6/27/to-pump-more-milk-

use-hands-on-pumping.html

Breast & Bottle Differences

Older babies

may transition to a cup

Introducing a Bottle

There’s LOTS more going on

than baby’s age, type of bottle

used



FILCA 7

On maternity leave:

• How often to bottle feed?

• How much to give?

Think “snack” rather

than “meal”

• 1-2 oz/30-60 mL per day

• Every 2nd or 3rd day

Peterson & Harmer. Balancing Breast & Bottle: Reaching Your Breastfeeding Goals. Amarillo, TX: Hale Publishing, 2010.

Bottle flows

faster, more consistently

• Can override

baby’s appetite control mechanism

• Contributes to overfeeding, obesity

Li, et al. Arch Pediatr Adolesc Med 2012; 166(5):431-36

At an average feeding, formula-fed babies

consume much more milk:

• 49% more @1 mo

• 57% more @3 mo

• 71% more @5 mo

& feed fewer times per day

Kramer, et al. J Pediatr 2004; 145(5):600-05

For the average

breastfed baby, feedings do

not vary much

in number & size from 1 to 6 mo

Kent, et al. Breastfeed Med 2013; 8(4):401-07; N=52

Fewer & larger

feedings over time is a

bottle-feeding

pattern

To avoid

overfeeding use pacing &

slowest flow

nipple/teat

For pacing details, see handout: For the Caregiver of a Breastfed Baby

Kassing. J Hum Lact 2002; 18(1):56-60

www.NancyMohrbacher.com/handouts/

Back to Work: Maintaining

Milk Supply

Long Term



FILCA 8

Expand your

focus beyond

number of

pump sessions

at work

Focus on 24-Hour Day

~ 30 oz/900 mL

per day needed

After 1 month,

an average

breastfeeding is 3-4 oz/90-120 mL

The Magic Number

Total # of milk

removals per dayneeded to maintain

production

long term

Main factor: Breast Storage Capacity

Mohrbacher. Clinical Lactation 2011; 2(1):15-18

If baby is exclusively breastfed, after 6 wk count # breastfeedings per 24 hr

A clue to storage capacity

And # milk removals per day needed to maintain long-term supply

Daily milk removals = breastfeeds + pumps

After returning to work, try to keep stable daily total of milk removals

Many mothers pump enough at work but don’t breastfeed enough at home

As daily total drops,

milk production slows



FILCA 9

MORE

BREASTFEEDING

when together means

LESS PUMPED MILK

NEEDED

when apart

= 3-4 oz/90-120 mL

LESS milk

needed at work

Every breastfeeding

added

= 3-4 oz/90-120 mL

MORE milk

needed at work

Every breastfeeding

dropped

Reverse cycle nursing

• Breastfeed most when mother’s home

• Longest sleep stretch when mother’s at work

Impact of the Longest Stretch

Always ask its length

“Full breasts

make milk slower”

Usually at night

– May be ≥12 hr

– 8 hr works

for some but not all

# Milk Removalsper Day Needed

to:

Largest

Capacity

Large

Capacity

Medium

Capacity

Small

Capacity

Smallest

Capacity

Increase milk 4-5 6-8 8-10 10-11 ≥12

Maintain milk 3-4 5 6 7 8

Decrease milk 2 3 4-5 6 7

Daily Milk Removals & Supply

Largest

Capacity

Large

Capacity

Medium

Capacity

Small

Capacity

Smallest

Capacity

Max longest stretch

10-12 hr 8-10 hr 7-8 hr 6-7 hr 4-5 hr



FILCA 10

Calculating Baby’s Milk Needs

~30 oz/900 mL in 24 hr

Mother’s away 8 hr

• 8 hours is 1/3 of 24

• 1/3 of 30 oz/900 mL = 10 oz/300 mL

Average—may be more or less

Assumes baby feeds at night

~30 oz/900 mL in 24 hr

Mother’s away 12 hr

• 12 hours is 1/2 of 24

• 1/2 of 30 oz/900 mL = 15 oz/450 mL

If apart 8-12 hr, baby needs

~10-15 oz/300-450 mL

Assumes baby feeds at night

816

8 hr sleep = 30 oz/900 mL in 16 hr

12 hr sleep = 30 oz/900 mL in 12 hr

1212

If Baby Takes Much More, Find Out Why

Bottle too full, milk discarded

Over-feeding

Too little breast-feeding

The Magic Number

Many mothers pump enough at work, but don’t breastfeed enough at home

As daily total

drops, milk production

slows

Troubleshooting

with Employed

Breastfeeding

Mothers



FILCA 11

“My baby is taking more milk than

I pump at work. What should I do?”

~What is your first response?~

Before answering, ask:

• Volume of milk expressed

• Volume of milk fed

• Times per day she:

– Breastfeeds

– Expresses milk

• Magic Number when

home & daily total now

• Length of longest stretch

• 24-hr routine

May Also Need to Know…

• Is baby eating solids?

• Pumping issues?

‒ Pump quality, malfunction, fit

‒ Milk-ejection issues

• Galactogogues used?

• Mother or baby health issues, meds

(birth control)?

1: Jen & Colin

“My baby is taking

more milk than I pump at work.

What should I do?”

Baby Colin 10 wk old

Jen@work full-time 2 wk

1: Jen & Colin

Magic Number @home: 8

Apart 8 hr

• Colin taking 20 oz/600 mL

Jen can’t keep up

• Jen pumps 12 oz/360 mL

Expected volume

• 8 hr apart = 10 oz/300 mL

• Colin taking twice the milk expected

1: Jen & Colin

Breastfeeds 1x am, 2x pm, pumps 2x at work, sleeps 8 hr at night

• Now daily total = 5 (Magic Number 8)

Colin is fed four 5oz/150 mL bottles

• 1 at arrival at caregiver

• 2 during day

• 1 just before Jen arrives

What is the issue? What can Jen do?



FILCA 12

2: Abby & Beth

“My baby is taking more milk than I pump at work. What should I do?”

Baby Beth 6 mo old

Abby@work full-time 4 mo ago

2: Abby & Beth

Milk issues @3 mo

Magic Number @home: 8-10

Early, Beth slept 10-12 hr

Abby@work 4 mo ago, apart 8 hr

• Milk dropped right away

• Pumped at night so as not to wake Beth

• Used herbs to boost milk production

2: Abby & Beth

Abby dropped night pumps• Longest stretch: 10-12 hr

When herbs stopped, , milk supply drops, uses formula

Dropped feedings over time

Now daily total = 5 (Magic Number: 8-10)

• Pumps 2x at work, breastfeeds 3x at home

• Pumping 6 oz/180 mL in 8 hr at work, Beth takes 12 oz/360 mL in 8 hr

What is Abby’s issue?

3: Josi & Claire

“I pump less milk at work than I used to. What can I do?”

Baby Claire 8 mo old

Back to work full-time 5 mo ago

3: Josi & Claire

Magic Number: 8

Josi@work 3 mo, away 9 hr

Milk stable until ~6.5 mo

• Pumped 12 oz, now 9 oz

• Daily total now: 8

• 3 pumps@work + 5 BFs@home

• Longest stretch: 8 hours

What’s affecting supply?

3: Josi & Claire

What caused the change?

Milk intake

• Increases birth to Week 5

• Plateaus (until ~6 mo)

• Decreases with solid foods

Questions to ask:

• Is Claire on solid foods?

• If so, how much?

Does Josi need to increase her milk?



FILCA 13

To Increase

Milk Production

The sooner, the better

Increase daily total of milk removals

• Breastfeed more

• Pump more

Drain breasts more fully each time (Drained breasts make milk faster)

− Use hands-on pumping

− Check pump fit Jones & Hilton. J Neonatal Nurs 2009; 15(1):14-17

If using milk from freezer stash every day,

find out why & adjust

To wean off,

• Pace all bottle feeds

• Gradually reduce extra milk while breastfeeding more

• Pump at home

Breastfeeding Does Not

Have to Be All or Nothing

One Size Does Not Fit All

Tailor strategies

to different:

• Jobs

• Babies

• Family dynamics

• Maternity leaves

• Storage capacities

• Body responses to pumping

Knowing how

breastfeeding works clarifies what

needs attention &

what can be ignored

• Planning during pregnancy

• Maternity leave

• Milk norms

• Breast & bottle

differences

• Keys to meeting long-term goals

• Troubleshooting



FILCA 14

[email protected]

www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC

Pinterest.com/nancymohrbacher@BFReporter

www.YouTube.com/NancyMohrbacher

~

Working & Breastfeeding Made Simple · Every breastfeeding added = 3-4 oz/90-120 mL MORE milk...

Documents

Transcript of Working & Breastfeeding Made Simple · Every breastfeeding added = 3-4 oz/90-120 mL MORE milk...