Breastfeeding Your NICU Grad

 

Coming home from the NICU can be a scary experience. Your baby has been cared for by so many specialists and now what? I remember thinking “Can I do this? How can I possibly be as equipped as the NICU?” You can and you are, but that doesn’t mean you don’t need support, especially with feeding. Here are some common concerns parents have:

 

·       Is my baby getting enough? How can I tell?

 

NICU babies are often supplemented while in the hospital, particularly if they are preterm or slow to gain weight. Your pediatrician as well as the neonatologist who discharges your baby can advise you on how much and for how long you need to supplement breastfeeding at home. I usually advise parents to continue supplementing as they have been in the hospital until the first pedi appointment. This may mean supplementing after every breastfeeding session, but the first pediatrician visit is often within a few days and you can re-evaluate then. If your baby is going home well before their due date or was very preterm to start, they may need supplementary calories in the form of fortified breastmilk or higher calorie formula. This is usually temporary and once baby is closer to term and gaining well they can transition to exclusive breastfeeding/ breastmilk. Watch baby for signs of adequate output (6-8 wet and 3 stooled diapers – stools may decrease by 4-6 weeks) and feed at least very 3 hours, even at night. One thing that can be helpful before you leave the NICU is to do a test weight*. This involves weighing baby before a feeding and then after to see approximately how much baby is transferring at the breast. This is also something you can do post discharge at your doctor’s office or in home with a lactation consultant (more about that later). A few test weights can help you see what an adequate feeding looks like for your baby. 

 

·       My baby is so small!

 

Recent advances in preterm care have led babies to go home sooner than they did in the past and for most hospitals, if baby is larger than 1800 grams (about 4 pounds) and meeting all of the other criteria for discharge (usually all feeds by mouth and maintaining temperature and heart rate/breathing) they can go home. This can mean you are breastfeeding a very small newborn! I believe strongly in a good supportive pillow, such as the Brest Friend that will lift baby up to you and provide firm support. A couch pillow can also be good, as it’s usually stiff and will lift baby higher up. The football position is good for small babies, as you have lots of control and can see everything that is going on with them re: breathing, latch, etc. If your baby gets very sleepy in this position the cross cradle is also a good one. See some photos here. Overall remember that babies are heartier than you think and grow pretty fast, but it’s normal to be nervous.

 

·       I’m using a shield – how do I stop?

 

It’s not unusual for babies in the NICU to breastfeed with a shield. Preterm babies often fatigue quickly at the bare breast and need the extra support of the shield to maintain an active suck. Other babies are used to the feel of the bottle nipple and find it easier to go between breast and bottle when using a shield. When I had my first NICU baby (31w), I was completely against shield use and felt my baby wasn’t truly breastfeeding if using one. After talking with the lactation consultant on the unit and reading some research, I was open to the idea and it did help my baby begin to learn breastfeeding. As he grew stronger and my milk supply increased we were able to wean off the shield. It’s important to realize that a shield is just a tool and with or without it your baby is still feeding at the breast. Once baby is consistently breastfeeding, you can try starting with the shield and then, after baby is in a good pattern (5m or so), you can take off the shield and return baby to the bare breast. Use breast compressions to keep milk flowing and some chin support can also help baby keep the latch. Rachel O’Brien, IBCLC has a great blog post about weaning off the shield and you can find that here.

 

·       Am I doing this right??

 

This is where a lactation consultant can be so helpful. Hopefully you worked with one (or a few) in the NICU but did you know that many lactation consultants do home visits? The “gold standard” in lactation care is the IBCLC or International Board Certified Lactation Consultant. IBCLCs have gone through 500-1000 hrs of breastfeeding counseling as well as college courses, lactation specific classes and a fairly rigorous exam to become certified. I would definitely recommend using one. Many insurance companies will reimburse for lactation care and some IBCLCs are able to bill certain insurances directly. The best bet is to go to ILCA and search for an IBCLC in your area. Another option is Zipmilk, although this directory does not serve every state. Finally, your local NICU may have someone they recommend. A home visit can include a weight check (*including a test weight), latch assessment, pumping guidance (including flange fit), and help with a breastfeeding plan to meet your family’s needs. You may be doing just fine, but it’s good to have that confirmation and reassurance.

 

 

 

You and your baby have a come a long way, so don’t forget to give yourself time to make this transition. Baby showers, visitors and welcome home parties can wait while you and your family enjoy this time together and settle in. It’s always ok to say “Our baby just came home from the NICU so we are limiting visitors for now.” Settle in, hydrate, rest when you can and if you are having trouble with breastfeeding ask for help – you are worth it!

Wash Your Hands...and Breastfeed!

The recent news about COVID-19 and influenza is scary for everyone, but if you have a newborn you can feel particularly vulnerable. The good news? Breastfeeding provides extra antiviral protection for your baby and, should you get sick, you can usually continue to breastfeed. How can you protect yourself and your family? WASH YOUR HANDS. We are tired of hearing it, but this is the single most effective way to avoid spreading illness. I would also suggest limiting crowd exposure, airline travel and visits with anyone who has symptoms of illness. Most respiratory viruses are less active in the warmer months, so this will not last forever. In the meantime, seek help if you are having trouble with breastfeeding, spend more time at home with your baby and WASH YOUR HANDS!

Here are some helpful links: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/influenza.html

https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-guidance-breastfeeding.html

From A to Z

Advantages of Breastfeeding

Anti-biotic/anti-infective                                 

Better for the environment

Cannot be duplicated

Diabetes risk is lower

Easy to prepare

Free!!

Gut friendly

Heart healthy

Intelligence raising

Just the right temperature

Keeps refilling

Little waste

Mom’s reduced risk of breast cancer 

Needs no sterilization

Obesity reducer (mom and baby)

Poops smell better

Quickly digested

Ready day or night

SIDS risk reducer

Tailored to the age of the child

Uterus tightener

Very nice containers

Won’t stain clothes

Xtra nutrients

Yummy for baby

Zero recalls!

Induced Lactation - Can it be Done?

I have been fortunate to work with a variety of parents over the years, with many different stories. One of these is the process of inducing lactation in a non-birthing parent. Induced lactation is hard work, but can be very rewarding. There are three main things to keep in mind: You may not make a full supply, any amount of breastmilk is beneficial, and what works for you and your baby may not be what works for someone else.
When counseling parents I start with my go-to book, Breastfeeding without Birthing. Alyssa Schnell's book has tons of information about starting the process of inducing a milk supply, methods to make milk and how to navigate challenges along the way. The next step is to find out what your goals are - do you want to exclusively nurse your baby? Are you ok with supplementing? Will there be someone else also breastfeeding the baby? It is important to make sure you have support from your partner or family and that they understand how important this is to you. Induced lactation requires time and patience (often before baby is even here) and will be much easier with support. 

Your medical team is also a key part of this process. If you don't already have a doctor who is knowledgeable in this area, ask around to find someone who understands induced lactation and can work with you to achieve your goals. Some parents choose to use medication - the Goldfarb protocol is a popular and often effective method to induce lactation. Check out some of the Facebook groups for non-birthing parents wanting to breastfeed, as peer support is also  helpful when going through this. Finally, if you will be present for baby's birth, make sure your delivery team knows breastfeeding is important to you and can support you in the postpartum period. Skin to skin, early pumping and rooming-in can all help you get off to a good start. 
Last but not least, the nuts and bolts - a good pump and a hands-free pumping bra! The most effective pump is a hospital grade, double electric pump. Most insurance companies cover an electric pump, but ask if they will cover a hospital grade for inducing lactation. You can also look into renting a hospital grade pump. A standard electric pump is ok too, just make sure it is well rated for suction and durability. I don't recommend a used pump, both for hygienic and utility (those motors don't last forever) reasons. The newest trend, a hands-free pumping bra can make your pumping life much easier and is more effective than the hands-free pumps on the market (these are often lower strength). 

It's tough to induce lactation but it can be so enriching; don't forget that any amount of breastmilk/breastfeeding is beneficial for you and baby and that your journey belongs to you!

Self Care

I used to hate the phrase "self care". It felt New-Age and entitled and brought to mind a woman in a bubble bath with cucumber slices over her eyes. Now I think of self care as anything that makes my day easier, like a piece of dark chocolate or 15 minutes sitting in the sunshine. Is it possible to practice self care with a newborn? Yes, but we need to re-frame what this means. Aphorisms like "sleep when the baby sleeps" or "take time for yourself" or even "you can't pour from an empty well" can make new moms feel discouraged and inadequate. Here are some basics and above all, know that you deserve this.
How about beginning with things you are not going to do? Here are some examples:

• Minimal social media (check Facebook for 5 minutes at the beginning and end of the day, e.g.)
• No attending social events you don't like
• No checking work email after 6pm

Exercise is good for mind and body, but let's be realistic:

• Walk to the mailbox daily
• Use home equipment 10 mins per day
• Carry baby in a sling or carrier 

Eat right but make it easy:

• Keep frozen meals and veggies on hand
• Make up a dozen hard boiled eggs at once 
• If friends/family ask what they can do to help, say "a meal would be great" (trust me, people want to know)
• Keep a small basket with a granola bar, water bottle and your phone - grab it when it's time to nurse and take it with you

Avoid isolation:

• Call or text someone every day (this is tough but you can always ask a baby question!)
• If you can get out, go to the library once a week - baby-friendly, nice bathrooms, and always temperature controlled!
• If you'd like to go to a mother's group but it feels like too much, try an online one

SLEEP (Just because you have a baby doesn't mean you don't deserve sleep!)

• Rest your body when you can - **remember that this helps, even if you are not asleep
• Consider getting a weighted blanket (not for baby) - this can help reduce anxiety and let you get a better quality sleep, even if for a short time
• When baby is sleeping, get into your bed (under the covers, etc.) and rest **

What is Perinatal Mental Health?

I recently became certified in perinatal mental health, a field that I am passionate about. I see so many moms struggling through the first year with a baby, trying to juggle the demands of home, work and relationships while usually getting very little sleep. Postpartum depression and associated mood and anxiety disorders are much more common then you think. It's estimated that 20% of all new mothers are suffering and if baby is in the NICU that number doubles. The problem here is that perinatal mental health is different from general mental health care in that you are treating two people (more if multiples)! Many psychiatric practitioners are not fully educated in prescribing medication for pregnant or breastfeeding women and OBs are often not comfortable stepping into a psychiatric role. The result is that new mothers are not getting the help they need and the effects of untreated mood disorders for both mom and baby can be disastrous. What can we do and how does breastfeeding affect maternal mental health? The first and most important thing any practitioner can do it to listen to mom, let her talk about how she feels and what scares her, and let her know she is not alone. We know that when breastfeeding is going well, the risk for PMADs is lessened. However, in moms who want to breastfeed but are struggling or in moms who did not intend to breastfeed but feel pressured to do so, the risk is multiplied. How many times have I heard moms say that they felt pressured or guilty or even shamed for not breastfeeding. We need to do better. We need to support parents where they are and understand that a happy, healthy mother contributes to a happy, healthy baby. This may mean breastfeeding, supplementing or formula-feeding but moms need support first and foremost.

Holidays and Plugged Ducts

The winter season is upon us, and one thing I always like to talk about is plugged ducts. No, really...we see them so much more around holidays! Often it's because well-meaning friends and family want to hold and enjoy your baby and then feedings are delayed. Moms can also get run down, with too much activity and not enough rest. If you feel yourself getting a plugged duct (hard, sore area that may be reddened), do these three things: rest, use warm compresses (or a hot shower w/ massage), and feed very, very frequently. The secret to heading off a plugged duct before it moves to mastitis is to keep emptying the breast. In my old La Leche League days, we used to say, "Go to bed with the baby and don't stop nursing!" Now of course, co-sleeping is discouraged by the AAP, but you can still rest and feed all day long if you are able. If you begin to develop a fever, chills, or generally feel like you have the flu, call your doctor (OB or your primary care doc). You may need antibiotics, but DO NOT stop breastfeeding! If your doctor tells you your antibiotics are incompatible with nursing, DO call you lactation consultant  - many docs are not up on the latest research around medications and breastfeeding and we can give mothers information to take back to their doctor. If it is simply too painful to feed at the breast, you can pump, but try not to use bottles in the first month (there are other feeding methods). Finally, a plugged duct and/or mastitis should serve as a sign to slow down, take care of yourself, and maybe dial back the holiday frenzy a bit. I always say to moms - "It just has to be good enough" and it's true. Use the packaged pie, the ready-made cranberry sauce (who doesn't love that anyway??), and if people are coming over - just make sure the bathroom is presentable. You are doing something no one else can do for your baby and that's pretty damn important!