#264 | Breastfeeding Q&A: Pacifiers, Pumping, Bottles, Domperidone & IGT, Flat Nipples, Weaning and Breast Implants

May 8, 2024

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Welcome to our first breastfeeding-only Q&A with Trisha & Cynthia. Trisha is a Certified Nurse-Midwife and International Board Certified Lactation Consultant with thousands of hours of clinical experience. Today's episode follows the format of our regular monthly Q&A episodes, where women call in with questions and we wrap up with Quickies at the end, but this time it's your breastfeeding questions only. Today Trisha answers questions such as: 

  • Can I introduce a pacifier to my exclusively breastfed baby at two and a half weeks?
  • Is it a nursing strike or weaning: Help! My eleven-month-old is refusing my breast. 
  • What is the best way to manage pumping for my exclusively breastfed baby when I am away?
  • How and when do I introduce a bottle to my exclusively breastfed baby so that I can leave him/her with a caregiver?
  • What are your thoughts on using the medication Domperidone with a diagnosis of Insufficient Glandular Tissue (IGT)?

In our round of Quickies, we touch on leaking, supplements for increasing supply, prenatal hand expression of colostrum, alcohol and breastmilk, breast refusal, lip blisters, breast fullness and milk supply, and flat nipples.

Please remember, that every mother and baby dyad is unique, and breastfeeding issues require an individualized care plan. Online appointments are available with Trisha by texting 734-649-6294.
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View Episode Transcript

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

A whole episode dedicated to you and your breastfeeding wisdom, we get all of our questions every month to our number eight oh, to get down. It's 802-438-3696. And we do get we get a lot of breastfeeding questions. Even breastfeeding experts out there are going to you because you're you're you're the one that they too are going to. So we decided to pull some of those and just put them into a breastfeeding q&a. And we're going to answer we're going to bang those out now. So there were just too many to fit into the regular monthly Q and A's. So are you ready to go? Is there anything you need to do to prepare to feel?

No, I think I would just say that it's so important with breastfeeding to get individualized answers to your questions based on your specific situation. It's so difficult to Google a breastfeeding answer and it can so mislead you. And that's what so many women do. And you can get the exact opposite information, if you Google a breastfeeding question for what is actually going to work in your specific scenario, because we're talking about a mom and the baby every single time. So there will never be a case where the same thing applies to every diet, you have a different mom, you have a different baby. And that makes every diet unique. So I'm gonna give more generalized answers today. But pretty much every question is going to come with a disclaimer, you know, you should seek individualized care for your situation. And the good news is that can be done online today. So that's a really helpful new asset in the breastfeeding world that mothers can get care anywhere in the world, anywhere in the country online. Nobody believed that would ever work years ago, until we were forced to do it and to help mothers when you know, during those those years when nobody was visiting other people. Nobody was doing face to face anything

- the Word that shall not be spoken.

Exactly. We won't say You don't say. Yeah. And but the access is so abundant now. And it's wonderful. So yeah, I remember when we both transferred our work to online, and we were both freaked out about it. And then we I remember when we will sit actually this is going really well for our clients. And we didn't expect that. So I'm teaching HypnoBirthing on Zoom, we have people from all over the country working with both of us. You're taking at least half of your breastfeeding clients on Zoom now, aren't you?

Yes, there. Yes. And the nice thing about that is that it can be you can get in so fast, you can get a you know, a half hour or 45 minute or an hour canceled if you need it much more quickly than if you have to book an in person appointment, which can be a week later and then breastfeeding world. A week is a month, everyday matters. So and by the way, we're gonna have quickies at the end of this episode like a regular q&a, which I think oh yeah. And there are like hundreds of them. So rolling. I pick a few. But yeah, people have a lot of breastfeeding questions. Anyway, let's get into the questions. Okay, great.

Hi, Cynthia and Trisha, my name is Margaret. I've been listening to your shows around my whole pregnancy and now I have just given birth to my beautiful daughter about two and a half weeks ago. She is exclusively breastfed, and I haven't introduced the bottle or Patty or anything up until this point but I am curious about beginning to enter Use it for exactly what it's used for pacifying at times because I do feel as though she can be fussy, and I'm worried just about nipple confusion and all of that. So just interested on what your thoughts are about introducing a patsy to my exclusively breastfed baby, she's about two and a half weeks old now. Thank you so much.

Okay, so my thoughts on this are, I am not opposed to pacifier use and exclusively breastfed babies, but I do think it is best to wait to introduce it until breastfeeding is well established which, at the minimum, two to three weeks, your baby needs to be back to birth weight, you need to be breastfeeding without any difficulties without any complications without any nipple pain. And I don't think pacifiers and exclusively breastfed babies should ever be the default, it should still be breast first. But if your baby doesn't want your breasts and are having a little bit of a hard time settling down, you can try pacifier for short term use. So just being very judicious about when you use it and how long you use it. Because certainly, we don't want to take away any sucking opportunities at the breast, because that is what gets your supply in sync with your baby's demands. So if you use a pacifier too much, you can limit the amount of time the baby's at the breast which is going to ultimately impact your milk supply. Most many in many cases, breast exclusively breastfeeding babies don't even take a pacifier. They just get their second needs met at the breast and they might try it or spit it out. Some will take them some some won't a lot don't. Using a pacifier in situations like a car ride, or during a diaper change or if somebody's holding the baby while you're in the shower and they're, you know, just kind of waiting for you to get to them intend to them and feed them. That's fine. You can also just use an index finger, just like your baby stuck on your finger to calm down sometimes babies, especially if a mom has a lot of milk, they may not want to they may want to pacify but they may not want more milk. So they may just suck on a finger or a pacifier to calm down. Baby wearing is also a great alternative to pacifiers, if you're having a hard time calming down your baby. Just pop them in a sling, start walking around the house. They'll calm down your babies and my babies. None of them took pacifiers, right yours were exclusively breastfed mine worked specifically breastfed and it just never happened. I tried. Never worked. Yeah, I I didn't really try. I told you recently I think it was in a Patreon but I said I was always kind of jealous of the women who've just popped it a pacifier and their babies were calm because I was at all why am I not doing this? But I didn't.

It's much more common for bottle fed babies to need pacifiers because they don't actually get enough suckling time. And they don't get the same oxytocin effect that the baby gets at the breast.

Hmm. You know, like those car rides where you they're inconsolable and everything. That's really hard. Yeah,

that's exactly that's when a pacifier can be handy. Yeah, but breast first, always press first.

I name is Patricia. First of all, thanks so much for all y'all do for our birth community and your family. I have a question about breastfeeding when you're away from baby. For example, I'm a doula. So I'll be away from baby for a few hours. And wondering how to go about pumping in that timeframe and look at best recommendations are, luckily, I've been able to pump a little bit every day. So she has plenty to consume while I'm doing my doula work, or outside of the house. Thank you so much again, for all you do. But

this is pretty simple, easy answer you pump about every three hours. That's usually what, on average, a baby's feeding every one and a half to three hours during the day. And when you're away from your baby, your breasts are going to fill. And because they're not nursing, you're going to need to relieve them. If you go beyond the three hours someone can make it to four. But you might get a really full and uncomfortable, which is not a great thing. So it's really simple. You just pump around the time you would feed or about every three hours, usually 10 to 15 minutes, bring your milk home, store it or leave it for the next day for leaving in. But yeah, it's it's not as complicated as it seems. If

they do this to they have to feel like they've emptied the breasts and pumping or just relieved the breasts of all that pressure.

I discourage mothers from trying to think about always emptying the breast too much because it's never really empty. It's always making milk even when you're pumping. It's refilling. So just pump until you're comfortable. Typically a baby is drinking two and a half to four ounces per feed. So yeah, pump about the amount that they drink at around the time that they would eat or about every three hours and you should be fine. It's not as precise and scientific as we might like to think it needs to be right as we want it to be as we want it to be. Remember breastfeeding is not left brained, it's right brained. And we're always trying to make it more left brained and you know, scheduled and

it's better if you don't. Yeah, it's better if you don't it interferes with it. Exactly. Yeah. Like birth, like sex.

Exactly. Same, same concept.

The intro show. My name is Kaylee. I'm out of North Carolina, I'm having my third home birth in March of 2024. The question is around breastfeeding and pumping. This will be my first time really wanting to introduce a bottle. While I'm also breastfeeding my newborn. How do I manage a breastfeeding, pumping schedule? Like what is manageable? And I really just would love a more overview, kind of like a quick Deep Dive. And I know y'all touched on this, you know, here or there. But I would really just like an understanding of for the breastfed baby, how do I introduce that bottle so that he can be watched by a trusted adult or family member? You know, so me and my husband can fill out this. Like I said, it's my third baby. I never tried before, I've only exclusively fed my other two, I never even really wanted to do bottles. But this time, I wanted to change things up, have the bottle available, and to have a good pumping routine, to where I'm not always pumping, but to where I don't have too little breast milk to even support the bottle necessity. Anyway, thank you so much for your podcast. Hope you all get a chance to answer this question.

That was hilarious. She, she asked for a quick Deep Dive. And that was great. Let me see if I can do a quick Deep Dive. So the answer to this is that you can absolutely be an exclusive breastfeeding mom and have bottles in the mix too. That's totally fine. Obviously, if you're going back to work or something, you're going to need to do that. But if you are just wanting to have the occasional bottle so that you can be away from the baby for more than a few hours, that's perfectly fine to. Again, I don't recommend introducing any pacifiers or bottles in the first two to three weeks when you are establishing breastfeeding unless you're working with a lactation consultant, and you're specifically using them for a specific reason. But otherwise, after three weeks, breastfeeding is well established uncomplicated everything is going well you can try a bottle with the baby, if you wait too. Too far too many weeks, you can have a baby who refuses the bottle, I see that a lot. And then that can be more complicated, obviously. So introducing a bottle sometime after between, you know, three and six weeks here and there just maybe once or twice a week is fine. So that your baby's familiar with it. And then if you are working to store milk, I recommend just pumping one time a day, usually after the first morning breastfeed when your breasts are a little bit more full. Maybe you had a little bit longer stretch overnight. Also, many mothers, most mothers make more milk overnight. So if you breastfeed in the morning, and you pump after, you will probably have a little bit of leftover milk, half an ounce, an ounce, maybe an ounce and a half, something like that, you can store that on a daily basis to accumulate a little bit of storage. You don't want to store ounces, a day of milk otherwise, then you run into the oversupply issue. And then that can be the milk that you use for whenever you go out and leave the baby for the first time. If you're gone, again, more than that three to four hour timeframe, you're gonna need a pump while you're out. And then they bring that milk home and replace what you used. A hand pump. A manual hand pump is great for this because if you're let's say you're just going out to run some errands or having lunch with a friend and you don't want to bring your big old pump. You can easily use a hand pump in the car, you can use it wherever it's very discreet, and you can just give yourself that relief that you need. And that's it.

Hi, somebody's interested. My name is Abigail. I'm a first time mom had a home birth with my first almost a year ago in part. Thanks to you guys. And everything I've learned listening to your podcast. My question actually is about breastfeeding. My son and I he's 11 months old. He's had kind of a difficult journey with breastfeeding. But I'm happy to say that we've been able to breastfeed up until now. But recently he has started to refuse breastfeeding or like not be interested in it. We've kind of been going slowly with solid just stuff that my intuition told me he needed. So he's not fully on solids yet. And I'm just wondering, is it possible for an 11 month old to self wean this early? Or is it potentially like a nursing strike? We've had that happen before where it's just something you have to work through that I keep pumping while he's not wanting to nurse just to maintain my supply or should I just let it kind of happen where you know he kind of weaned himself this early, I was very open to breastfeeding, you know, up until two years plus or whatever he would want. But I'm just surprised that he's, he's not interested in breastfeeding mainly during the day at this age. So any advice or input you'd have, I'd really appreciate.

Well, 11 months is a little early to be weaning if, if he's not consuming milk in some other form. So a baby can lean earlier if they're getting bottles of milk. But 11 months is a little young to be exclusively on solid foods and not having a milk source. So it wasn't really clear from her question, if the baby is consuming milk and another form another way, another method.

Yeah, I would just I would assume not if she didn't specify. But what if What What if she is and what if she isn't?

Well, I would, I would be hard to imagine that an 11 month old would begin consuming enough on a daily basis through solid foods, they would still need milk. So yes, I would tell her to continue pumping and offer milk in a different way. If the baby is refusing the breast, sometimes these nursing strikes do happen, and you can resolve them. But the older the baby is, the harder it is. It can be to resolve them. But an 11 month old can drink out of a straw and Open Cup. sippy cup doesn't have to be a bottle. But they do still need some form of milk

for how long? Like a year through 12 months,

but then it's like a slow gradual process and we down. That's when you're supposed to introduce cow's milk, I don't think you necessarily have to introduce cow's milk can still be breast milk.

Well, what about you? There's nothing magical about cow's milk? No,

I, I sought to avoid introducing cow's milk. But that's what most people are told by their pediatrician. Yeah, no smoker formula until 12 months, then cow's milk. You don't need to do that. No, that's like saying to a cow drink milk from your mother and then transition to cat's milk. It is it that is exactly what that is exactly what that's saying. And that's a totally different constitution from human milk.

Well, plus, it's not maybe if you're drinking raw cow's milk, but it's still pasteurized homogenized milk that we're drinking. Yeah, yes. 11 months old for each mother to decide on her own. Right, given her on this particular mother, I do think this baby still needs to be on some form of milk. So she should continue to pump to keep her milk up.

Right. But we're formula you really is what you're saying. Right. So I'm sort of not just milk, which ideally, it's not breastfeeding formula. Yes, exactly. It's not milk. Okay.

Hi, Trisha and Cynthia. This is Liz Britt, living in Texas. I'm curious to know your thoughts on the use of John paradigm for inducing lactation. I had my son six, almost six, six weeks ago now. And Breastfeeding has got off to a rough start with a suggestion that I might have IDT. And my lactation consultants suggested don't pair it on the internet reviews cuz it looks sketchy. And so I'm curious to know what your thoughts would be. I love the show. Thank you. Bye.

Big Question. Big question here. Okay. Yeah, okay. Throw me throw me right into the fire in our first breastfeeding episode. can take the heat. Okay, handle. So IGT stands for insufficient glandular tissue, that just means a breast that is underdeveloped and didn't didn't necessarily develop enough mammary tissue to produce a full milk supply or have a compromised milk supply.

Oh, wait, that that's interesting. Does a woman know if she has that? Like, does the breast fully form and look like a full complete shape breast by the time she's through puberty? Does it appear different for one? It

does, but breasts come in so many shapes and sizes, that this isn't something that a woman would necessarily notice but a clinician would know are some distinct characteristics. They tend to be wider spaced, and a tubular shape rather than round. Oh, interesting. I always thought that would have been a genetic thing if women had a more tubular shaped breast. Well, it could also be the also be genetics. Oh, that's very interesting. So she doesn't know No woman can look at herself and she has never had a baby yet and evaluate her breasts on her own. And I would hate to have women looking at their breasts and making that determination because even women with IGT can breastfeed, so you just don't know. But yes, if they have underdeveloped mammary tissue, they will have a harder time making a full milk supply. And for many women, they don't help so the question sorry, sure. Um, first question is How common is it?

Do we think it's not very common? Usually not actually very common? I think it's overdiagnosed? I don't see it very often. In my clinical work, and I see a lot of mothers with low milk supply.

So those low supply is not from IGT.

It is a reason for low milk supply. But there are so many other reasons for low milk supply that that shouldn't be your initial thoughts. Just one other comment IGT often women who do have it don't experience any changes in their breasts and pregnancy, so they may not feel the same growth of the breast and pregnancy. And that can be an indication that you could have IGT. Also, it can be sometimes it's genetic. There's congenital cases of it. And then there is also acquired cases of it. And there are various reasons that that could happen. Acquired IGT what's one reason for that, like breast reduction surgery or something? Definitely,

breast reduction, surgery, chest traumas, radiation to infants chest, even some there is even some association with certain viral infections. But in those cases, most people don't know the cause. Okay. So this woman is from Britain, she should fly home and go get some dumb paradigm. It is not FDA approved in the United States, it's very difficult to get. It's used in many other countries. Actually, we should we should read the FDA statement on down paradigm. But I'm going to do that. And then we're gonna talk about it. The FDA says although down Peridot is approved in several countries outside the US to treat certain gastric disorders it is not approved in any country, including the US for enhancing breast milk production and lactating women and is also not approved in the US for any indication. The agency is concerned with the potential public health risks associated with Domperidone. There have been several published reports and case studies of cardiac arrhythmias, cardiac arrest and sudden death in patients receiving an intravenous form of Domperidone that has been withdrawn from marketing in a number of countries. In several countries where the oral form of Domperidone continues to be marketed labels for the product contains specific warnings against use of Domperidone by breastfeeding women. And note that the drug is excreted in breast milk that could expose a breastfeeding infant to unknown risks. Because of the possibility of serious adverse effects. The FDA recommends that breastfeeding women do not use down paradigm to increase milk production. The FDA does recognize the immense health benefits that breast milk provides for nursing infant and is taking these actions today, and is taking these actions not to discourage women from breastfeeding, but rather to warn them not to use this particular drug when they're breastfeeding. So there are there there are studies that are that looked at the transfer of Domperidone into breast milk, which of course, almost every medication does transfer into breast milk and to some extent, but data that has been analyzed shows that there are no adverse effects in published cases of breastfed infants whose mothers were taking down paradigm. There was one case of an arrhythmia in an infant, but that was an arrhythmia with an unknown cause and unknown time of onset. So unfortunately, Domperidone is not available for clinical use in the United States. It is however, used extensively in other countries. Jack Newman has used it in 1000s and 1000s of women in Canada with great success and very few adverse effects. There are some published reports of side effects. But just like any medication, there are risks to medication. The alternative to Domperidone is reglan, which has many more side effects and is actually prescribed for women to increase breast milk. The way that both of these medications work is that they increase prolactin levels. The problem with using a medication to increase breast milk supply is that there are so many other underlying reasons that a woman could have low milk supply, and medication should never be the first line of action. You need to make sure that all other clinical indicators of breastfeeding are on track such as baby's weight gain and could latch and rule out tongue tie and all of those things before going to a medication. But unfortunately, Domperidone does work very well to increase breast milk production and its uses and its use is limited if not completely unavailable to women in this country.

Alright, quickies ready.

I am ready. Let's go. We got lots of them here. So we're gonna just pick a few okay. Is it common to leak any dry pads or is that not normal? Yes or no? Many women leak many women don't.

Some of them don't leak even in the first few weeks.

Not a lot. And you can still have plenty of milk and not leak. But most I would say most need to wear breastfed. What are the actual essentials? calls for breastfeeding and what is nice to have your breasts. That's it. That's the only tool. Everything else is nice to have. Can you breastfeed with breast implants? Absolutely, yes. And you can breastfeed exclusively with breast implants, I do recommend working with a lactation consultant to make sure that everything is on track, though, because it can be more challenging. Do any supplements really work to increase supply? They do. The supplements that are available, there are many herbs that are helpful in increasing prolactin levels. So prolactin is a hormone that helps us make milk. And if you can increase your prolactin levels, then your body can be more responsive to milk making through stimulation, but there's no food. There's no supplement herb that's going to make you make more milk without properly effectively stimulating your breast. Should I start hand expressing or pumping before the baby arrives, where you could pump if you're trying to get yourself into labor. But otherwise, you don't need to I mean, hand expression, I think is a really helpful skill to learn. And I know there's a big movement to collect colostrum before the baby arrives. And I'm not opposed to it. But I also don't think you have to do that. I do think getting familiar with your breasts and learning how to hand express your own colostrum or milk is really helpful to do in advance. So getting comfortable with it. Yes, but do you have to collect and store? No. Does alcohol actually get into your milk? Yes, it does. But in very small quantities.

Because milk is made from blood. And if we remember that they remember that everything they eat and drink goes in there. And but they don't have to pump and dump. Remember,

there's some feed your baby if you're in totally inebriated. Right, then the concentration might be too high if you have a drink fine. No problem. Okay, a couple more. Couple more quickies here. Let's see how to combat breast refusal. Unfortunately, you usually have to take a breast break. So how babies instincts baby's instincts to go back to the rest will remain intact. That doesn't go away. depends on their age, if they're young, maybe just a day could be up to you know, three or four if they're older, maybe a week. But also definitely work with somebody on that. Does a lip blister always mean a tongue time? It doesn't. But it is a it is a orange flag. My boobs don't feel full. Is there still milk? Yes.


Yes. Your stencil. Yes, your sense of fullness is not a good indicator of your milk supply in the very, very early days and weeks is more correlated, but later not at all.

Which is when breastfeeding gets so easy. Yes.

Last one. All right. I have flattish nipples. What do I do? flattish probably doesn't mean flat. I think so many mothers think they have flat or inverted nipples. And then I look at them and I'm like, nope, not going to be a problem. And don't go to a nipple shield. Because you think you have flat or inverted nipples. Your baby needs to learn to latch on your breasts, not the nipple anyway. There are many, many more, and we'll have to save some for next time people.

So we usually end with a personal question. But what on this? Do we?

How long did you breastfeed your children?

My children self leaned when they were between two and two and a half.

They both went to two to two and a half. Exactly.

Yeah. Wow. That right in between like two and a few months to I mean, the very last time they ever latched on like if they fell and bumped themselves and came to be consoled or like that was it. It was not frequent in the last few weeks or months, but yeah, that was it for them. That was when they both were ready. Isn't? Is that not normal? I started to assume that was kind of the norm.

No, that's totally normal that the world wide average, we've gone over this before.

And it's lunchtime now I totally doubted it like over four years old. It's insane. Insane. If that's an average, I know it's when states is pulling down that average. That's dramatically though shocking, because like, how many babies are breastfeeding until age? I find it so hard to believe that many babies go to that old because my babies were definitely done when they were done just over two years old. So i How is it that like millions and millions of babies are going to age four or five? Like, are they being encouraged? Are they malnourished? Are they Is it because

they're in other parts of the world? Where Yeah, I think more it's more necessity or you know, clean water is difficult to come by. And so breast milk is still best. So my first weaned self weaned at 14 months. My second, I unfortunately, had to go on a work trip and was away from her for an extended period of time and that led to weaning it two and a half. My third 15 months no, my third was about 17 or 18 months. And that was a little bit incentivized by me. Right I remember we were having very, very frequent night nursing. Alright, that's it.

That was great. That was fun. Yeah, good.

Remember everybody if you are struggling with breastfeeding Do not wait to get help. Every mother and baby is unique and needs a tailored plan specific to their scenario. Don't Google your breastfeeding questions.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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