Breastfeeding/Lactation Consultant

Hi all,

So glad to have found this board and hope you can help... my baby is 9 weeks old and we are still breastfeeding, though she didn't latch properly ( I learned via a severely cracked nipple) until probably 4 weeks of age. She was also a very sleepy baby for the first several weeks, and even after she became more alert (now I can hardly get her to nap, she's so curious!), I've had a really hard time seeing/reading any of the classic hunger cues for her. Her weight gain has been slow (just now gaining 4-5 oz/week in the last 3 weeks or so), and the lactation consultants I've worked with tell me part of that is that I don't make enough milk. We've been supplementing a few ounces per day for weight gain reasons, but my main question is re: when to feed her.

When she is really calm, I can pick up on lip smacking and her brushing her hands past her face; other times she is fussy and I can't tell if it's because she's hungry or needs to nap. When I can get her to nap, she'll can easily go past the 3-3.5 hr mark (since last feed) without waking up to demand food. I offer the breast every 2-2.5 hours during the day (when she gets fussy); sometimes she eats like she's hungry, other times she'll only take 6-8 minutes before falling asleep (does that count as a full feeding?). I want to feed on demand, but I'm afraid that she would only demand a feeding every 3-4 hours during the day, or less often (she is good about waking up and demanding a feed about every 4 hrs at night). I want to let her nap (I know she needs rest to grow!) but then worry that she'll go too long before her next feeding. I feel so clueless about how to approach this! Thanks in advance for any help!

Generally we advise feeding on demand ... but not letting baby go more than 2 1/2 -3 hours MAX w/o offering a feeding during the day.  Since weight gain has been a problem for you, you should still wake baby to nurse every 3 hours or so at night as well, imo.

You mention you are supplementing.  Are you supplementing w/ pumped breastmilk or formula?  If you are using formula and not pumping to replace that formula your body will not adjust to making the correct amount of milk for baby.  If supply is an issue (and I don't know that it is based on the info you've given ... can you post a weight history as well as provide info about how often / how much supplement is being used), you should pump after several feedings a day to encourage your body to make more milk.

Did the LCs you work with give you any advice for increasing supply since they seem to think it is low?

Does the above help answer your questions about when / how often to nurse?  Also please follow up w/ answers to abvoe.

I usually recommend feeding at least every 2 to 2.5 hours (measured from start to start) during the day and at least every 3-4 hours at night if a baby is having difficulty gaining weight. I would also usually recommend pumping after each feeding to increase supply and offering breast milk as the supplement rather than formula.

If you aren’t making enough milk it’s b/c the baby wasn’t latched well initially. If the latch is ok now you should be able to make enough milk. The reason the latch is so important is not just for your comfort, it’s also so the baby get extract enough milk. When the baby is latched more toward the tip of the nipple it inhibits the flow of milk. When the baby is latched well the milk flows more readily and usually babies suck better too. Since the amount of milk you make is determined by how much is taken out of the breasts, getting a good latch is important for milk supply.

If your baby is fussy I’d offer the breast. Don’t forget to allow your baby to cluster feed b/c that’s when the baby will get more of the higher fat hind milk.

Here’s more about feeding routines and cluster feeding:

What's a normal breastfeeding routine?

http://parenting.ivillage.com/baby/bbreastfeed/0,,8n69dpmw,00.html

If the feedings are short it may be b/c the baby isn’t fully awake. Here’s more on encouraging better feedings:

Sometimes feedings are short b/c the baby isn’t fully awake. I usually strip the baby to his diaper and t-shirt then do some baby ‘sit-ups’ gently rocking the baby back and forth while I tickle the ribs and up and down the spine. If I think I have the baby awake, I’ll pause, do nothing and watch the baby. If he remains awake and starts to try to suck his fingers or makes some noise then I know I have the baby fully awake and it’s ok to pass him off to mom to bf. If the baby goes back to sleep as soon as I stop tickling him then I need to work on getting him more fully awake before handing him to mom to breastfeed.

Once the baby is on the breast he should suck deeply and rhythmically. If he pauses longer than about 5-10 seconds you can get him started sucking again with a breast compression. Hold your breast in your hand, very close to the chest wall, with four fingers on one side and the thumb on the other side. Firmly squeeze the breast pushing it toward the baby without sliding your fingers down. Hold for 10-30 seconds or so and then release. OR, you can try to get the baby sucking again by stroking under the chin toward the neck with moderate pressure. If you do a compression and/or a chin nudgie a few times and the baby doesn’t start to suck again, or only sucks a few little sucks, then you can take the baby off the breast.

If the baby comes off the breast before 10 minutes I might try to wake him again and put him back on the same breast. If you try to wake him, only try for no longer than 10 minutes. If the baby isn’t waking in that time try a bit later.

Here are some more links to help:

How do I know my baby is latched correctly?

http://parenting.ivillage.com/baby/bbreastfeed/0,,9jw927vm,00.html?ice=iv|hy|pp

Is my baby getting enough milk?

http://parenting.ivillage.com/baby/bbreastfeed/0,,8rr83zjm,00.html

And once your baby is gaining weight well for at least 2 weight checks I usually recommend weaning off the supplements as described here:

Weaning from supplements:

http://parenting.ivillage.com/baby/bbreastfeed/0,,9w8tjqsd,00.html

Generally we advise feeding on demand ... but not letting baby go more than 2 1/2 -3 hours MAX w/o offering a feeding during the day.

--I guess that's what I try to do, since I feel like often she does not demand to be fed (unless the fussiness/crying counts).

Since weight gain has been a problem for you, you should still wake baby to nurse every 3 hours or so at night as well, imo.

--We had moved to 4 hour stretches overnight with the LC's permission since I was so exhausted.

You mention you are supplementing. Are you supplementing w/ pumped breastmilk or formula?

--BM whenever I have it, formula when I run out.

can you post a weight history as well as provide info about how often / how much supplement is being used

--birthweight 8 lb 4.8 oz; low of 7 lb 10.3 oz three days after birth; here's the other ones I can find (hard to do with baby on lap! LOL):

2w0d 7 14.2
2w3d 8 0.5
3w1d 8 4.8
4w1d 8 7.9
6w3d 9 2.7
7w3d 9 6.5
8w2d 9 11
8w6d 9 10 (different scale)

I pump after a morning feeding and after two feedings in evening, I get about 0.5-1 oz each 10-15 min pumping session. She is a fussier baby so it is pretty hard for me to pump when my husband is at work. I also take Fenugreek 5 caps 3x/day and eat oatmeal to increase supply. They mentioned a bunch more herbs & prescriptions, etc. I could take but it has been such a trying 9 weeks I either will have the milk or not! and am not really interested in doing further herbs or meds.

Re: supplements, when discharged from our doctor’s LCs (at 6.5 wks), they told us to give 1-1.5 oz when she still seems hungry after a feeding, and/or after evening feedings. We had been doing 5-6 oz/day average but since some frequency days around 7 weeks she seemed to be drinking better and more satisfied after feedings, so we had weaned her weaned down to 2-3 oz/day (using the weaning protocol via Kathy’s link—thank you!). Doctor had been okay with her slow but steady gain, but at her 2 month visit (the 9 lb 10 oz weight) wanted us to go back up to 3-5 oz/day until her 4 month check-up.

Really appreciate the articles especially on improving the latch and on breastfeeding routines! I think I haven’t been letting her cluster feed in the evening so will work on going more with her lead there. Thanks so much!

Fussiness and crying definitley count as a feeding cue, and in fact are generally considered a late feeding cue.  It is perfectly acceptable to offer to nurse baby whenever she cries (even if she was fed recently), as this is one way babies naturally increase mom's milk supply.  This is really common, as kathy mentioned, in the evenings, when babies frequently cluster feed (but some babies cluster at different times of day ... it's not always in the evening.  in fact my oldest clustered for 2-3 hours before bed, slept great and then got up and clustered for 2-3 hours in the morning).  That's not to say that baby will want to eat everytime that she cries or that she is crying because she wants to eat.  Certainly babies cry for other reasons also.  But, nursing isn't just food.  It's also comfort.  So if nursing makes baby feel better, then it's a great parenting tool even if baby isn't hungry.  And let's face it.  When they're really young, they ARE hungry all the time.  And, as I said earlier, it's ok to nurse even if baby "just" nursed.  You're never really empty.

I think if baby needs the supplement to maintain a good weight gain pattern, it's best to be consistent and methodical.  When baby's weight gain is stable then slowly begin cutting back the supplement a couple ounces every 3-4 days until no supplement is needed (per Kathy's instructions that you referenced).  But you really can't gauge how much supplement baby needs or if baby needs supplement at all based on behavior.  Babies are fussy little creatures.  Both my girls cried after feedings or fussed during feedings, but I absolutely did not need to supplement.  They were objecting to something else ... reflux, overactive letdown, etc.  There are lots of reasons baby fusses.  It's just not a reliable indication of a need for supplemental milk.  Weight gain and diaper output are the only ways to know if baby is getting enough via nursing and / or if baby needs a supplement.

HTH