Time and time again I hear the same thing from families that end up having to supplement with artificial infant milk even though it is not what they had wished for this baby: "I was told not to pump at the hospital." "They refused to give me a pump at the hospital." "I was told to NOT pump for the first SIX weeks!!!" This all coming from IBCLCs working in the hospital setting, including those in Baby Friendly Hospitals, and some times even those working in private practice.
WHY? Aren't we IBCLCs the first ones to complain that our current healthcare system does not treat the individual? Why, then, would we give generalized recommendations to lactating parents? EVERY single dyad is DIFFERENT!! One size NEVER fits all when it comes to lactation and breastfeeding or chest-feeding!!
Birth Interventions Impact Breast Or Chest Feeding
The reality facing birthing parents in the United States is that obstetrics care is broken! Birth has been completely medicalized! Medical interventions have been proven to interfere with lactation and breastfeeding or chest-feeding. For more information on this, read Linda J. Smith's Impact of Birthing Practices on Breastfeeding or Michel Odent's Birth and Breastfeeding. The high incidence of medical interventions including the use of epidural anesthesia, pitocin and cesarean section birth impact the hormonal imprint necessary for the competent establishment of lactation. Yes, women CAN lactate after medicalized birth but there are repercussions that often DELAY the onset of lactogenesis two.
Lactogenesis is the change that occurs between the pregnant state and the lactating state. Lactogenesis has two stages: the first takes place during pregnancy and is when the mammary glands initiate functional capacity and a pregnant person begins to produce colostrum milk at approximately 20 weeks gestation. Lactogenesis two begins after the birth and occurs when the intact placenta exits the birth parent's body. Lactogenesis two is basically the successful transition between the production of colostrum (small quantities of highly concentrated milk) and mature milk (a more ample production). Lactogenesis two is driven by effective and consistent removal of milk.
After a medicalized birth, two compounding factors can impact the transition between colostrum production and the more ample production of mature milk. The first is the hormonal interruption the birth parent experiences after a medicalized birth. The second is the hormonal impact on the baby from a birth full of medical interventions. During the early hours and even days after a medicalized birth, it is common that babies do not successfully transfer milk even though the latch may look "good" from a peripheral observational point. Ineffective milk removal has two major effects: the baby does not receive enough hydration or caloric intake and in addition insufficient milk removal often translates into delayed onset of mature milk production (the more ample volume of production).
When we tell birth parents, as a matter of routine, without properly assessing infant milk transfer to NOT pump after birth and in the early days and weeks postpartum, we are setting babies up to be supplemented with artificial infant milk and this is what I see TIME AND TIME AND TIME again in my private practice!
What To Do After Birth
In my prenatal lactation education, I empower birth parents to know how their bodies work and the impact that medicalized birth can have on lactation and breastfeeding or chest-feeding. I recommend that birth parents hand express after every breast or chest feed starting with the second feeding session and that they collect that precious milk and supplement their babies after the subsequent feeds with their expressed milk in volumes appropriate for the age of the baby. I recommend birth parents do this during the hospital stay. I also recommend that if by 18-24 hours postpartum the birth parent is not collecting 5-7MLs of milk that they should continue to hand express for 3-4 minutes each breast then add pumping for 5-7 minutes to help achieve more effective milk removal thus facilitating optimal milk production.
Because excessive milk removal can cause or exacerbate over production, I educate pregnant parents that if they have to initiate pumping they should discontinue it when they start expressing 30MLs or more. I recommend that they contact a lactation consultant as soon as possible after the birth, while still in the hospital, so that their feeding and milk production plan can be individually tailored according to their specific birth and postpartum experience. You can find a local lactation consultant by visiting the International Lacation Consultant Association's website.
If our aim is to reduce infants' exposure to artificial infant milk, then we must STOP telling birth parents to not pump after birth, as a matter of routine, and instead we must educate them to understand how birth interventions can and do impact lactation and breast and chest feeding and we must give them specific guidelines to help them navigate the first 2-5 days postpartum in a way that facilities both adequate production and effective human milk feeding for their babies.
The best way to ensure an individualized care plan is to have an individual prenatal lactation and breast or chest feeding assessment with an IBCLC. This will not only facilitate more targeted, individualized education but it will also ensure that the birth parent has an established relationship with a lactation expert who will be available for support immediately after the birth.
Hand Express Your Milk, It Really WORKS!
In all my years of private practice, my 3 years as the WIC Breastfeeding Coordinator for Hudson County, a program which served over 30,000 families, and in my work in Hudson County hospitals with maternity services, I have only come across a literal hand full of babies that did not require supplementation, which means that in my personal experience thousands of babies have received supplementation, with artificial infant milk, which in most cases could have been completely avoided by implementing early hand expression followed by milk expression with a pump when indicated. Dr. Jane Morton, professor of pediatrics at Stanford University, whom I have seen lecture twice, has conducted a couple of studies which have shown that early initiation of human milk expression by hand is a significant factor in determining both the successful establishment of lactogenesis II, when colostrum production turns to more copious mature milk production, and the successful long term viability of competent milk production.
We need to take a look at what parents' infant feeding goals are and what the overall best health practices initiatives are to institute individualized care that meets both of these markers. Looking at a newborn at the breast for 10-15 minutes in a hospital room is not an effective way to assess milk transfer competency. Having birth parents hand express after feeds and collecting the milk to appropriately supplement babies is a very low key intervention with minimal if any risk factors for either baby or birth parent. Taking into account the birth parent's complete health history, specifically competent breast and reproductive health assessment, and closely evaluating the labor and birth history and related interventions is a responsibility that every healthcare provider that comes into contact with the dyad must uphold. If birth parent is not getting appropriate output from hand expressing after 18-24 hours post birth, it is prudent to evaluate the individual case and assess whether adding a carefully constructed and closely monitored milk expression plan that includes pumping is an appropriate next step to ensure adequate milk production and more importantly to ensure human milk feedings for human babies.