Part II – Goldi-Nurse and the Three Babies: What if Milk Supply isn’t Just Right?
Gloria Dudney, RN, BSN, IBLC, RLC
Gloria has been practicing maternal/child nursing for 30 years. She has experience in levels 1 & 2 newborn nurseries in Texas and Tennessee. She served 24 years at a private pediatric practice, where she launched the region’s first primary care lactation clinic. She now serves as director of lactation for East Tennessee State University Health.
Rachel and Sophie – The Story of “Just Enough Milk”
Rachel is a 38-year-old G2P1 with a history of advanced maternal age, PCOS, class II obesity, insulin-dependent gestational diabetes, and previous lactation failure following CD at 37 weeks. Now in her second pregnancy with her daughter Sophie, Rachel told her obstetrician how sad she was and continues to be that she could not breastfeed her first child, Connor. Her OB referred her for a prenatal lactation consult with an IBCLC to assess her risk factors and develop a care plan to support her long-term breastfeeding goals.
At her prenatal lactation consult, Rachel and her husband were able to process their emotions regarding Connor’s birth and breastfeeding journey. They shared that they attended a prenatal breastfeeding class that educated them on how breastfeeding works, but they wished someone had helped them prepare for what to do if breastfeeding was not working.
Her IBCLC validated their sadness and frustration before reviewing her medical risk factors and how they can affect lactation. Rachel stated that having that understanding allowed her to release some of her guilt. They discussed Rachel’s goals for this pregnancy and developed an individualized care plan for the remaining weeks of pregnancy into early postpartum.
Rachel listed the things she was frustrated about or felt unprepared for after her first delivery. After reviewing the list, they would control the things they could control and try to release anxiety about the remainder of the concerns.
She felt powerless over her previous surgical delivery and its effect on the breastfeeding journey.
Her first delivery required a c-section due to fetal macrosomia. Rachel was driven to avoid a repeat and began making dietary adjustments and intermittently monitoring her blood glucose levels in the early weeks of pregnancy. When she noticed elevations despite careful diet, she alerted her OB. The diagnosis was made earlier in this pregnancy, so her blood glucose levels were tightly controlled by the time she saw the IBCLC. She is hopeful that the fetal weight would not require a surgical birth. However, regardless of the delivery method, her primary goal is a better breastfeeding outcome with this child, Sophie.
Rachel felt frustrated by the delay in her milk coming in after the birth of her first child.
After the IBLC reviewed research and risk factors for delayed and suppressed milk production, Rachel was surprised to learn that PCOS, obesity, gestational diabetes, caesarian delivery, and infant of early term gestation are all situations that increase the odds of struggling to establish breastfeeding and breast milk production (Younger Meek, 2022). They developed a plan of action for encouraging maximum milk production during the first two weeks postpartum, also known as the calibration phase of lactogenesis II: milk removal from the breasts via nursing or hand expression as soon as possible after delivery, protect access to the breast for frequent nursing, hand expression of colostrum after nursing in the first two days post-delivery, double-electric pump for additional stimulation if milk onset is delayed. They discussed prioritizing milk removal from the breast to encourage maximum milk production, protecting long-term breastfeeding goals. See Table 1.
Table 1.
Rachel felt anxious about nursing because she was not sure the baby was actively swallowing breast milk.
They reviewed how to discern the difference between sleeping and shutting down at the breast. The baby is “asleep” at the breast and has finished the feeding if she has been actively swallowing during the feeding, comes off the breast with a relaxed body posture, and does not exhibit hunger cues after the feeding. The baby shuts down at the breast; she sucks and swallows intermittently, needs stimulation to continue suckling, and exhibits hunger cues when taken off the breast.
If Rachel notices that the baby is “shutting down” at the breast repeatedly, she may not yet be ready or able to remove milk from the breasts without assistance effectively. If this occurs, instead of “Just keep nursing,” Rachel’s mantra will be, “When in doubt, pump it out.” Since the window to establish robust milk production is more limited than the window of time to establish effective latch and direct breastfeeding, she will prioritize milk removal and triage her energies accordingly (Boies, 2016).
Rachel felt afraid to follow her instincts.
Rachel said that when she voiced concerns that Connor may not be transferring colostrum well due to how “sleepy” he was at the breast, she was told that was normal. Additionally, when he began to lose excessive amounts of weight and became significantly jaundiced, she inquired about offering a little formula to support his hydration and nutrition—she was told the supplement was not medically indicated. They discussed the clinical difference between low-risk and at-risk breastfeeding dyads. They reviewed the importance of protecting exclusive breastfeeding for a mother and baby who have no medical risk factors, but when those risks are present for mom and/or baby, limiting the plan of care to exclusive breastfeeding can be insufficient to maintain infant intake, build maternal milk production, and protect long-term goals (Boies, 2016). Her IBCLC encouraged her to use whatever adaptations were needed first to protect Sophie’s hydration and nutrition and then to protect Rachel’s milk supply, as those things ultimately protect the long-term breastfeeding relationship (Boies, 2016).
By the conclusion of her prenatal lactation consult, Rachel stated that she felt calmer and more confident about breastfeeding baby Sophie. She had educational resources, a better understanding of how her medical risk factors call for a flexible early feeding plan, and a follow-up plan to ensure she receives the right help at the right time.
Stay tuned to the next blog to learn more about Rachel and Sophie’s breastfeeding adventure following delivery!
References
Boies, E, et al. Breastfeeding the Late Preterm and Early Term Infants. Breastfeeding Medicine 2016: 11(10). 10.1089/bfm.2016.290031.egb
Joan Younger Meek, Lawrence Noble, Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics July 2022; 150 (1): e2022057988. 10.1542/peds.2022-057988
Rosen-Carole, et al. Breastfeeding Promotion in the Prenatal Setting. Breastfeeding Medicine 2015: 10(10). 10.1089/bfm.2015.29016.ros
Learn more about Mead Johnson Nutrition
The material presented in this blog represents the opinion of the author(s) and not necessarily the views of Synova Associates. Synova Associates does not endorse any specific products or organizations but strives to connect its industry partners with leaders interested in product/educational innovation.
