An Interview with Nancy Mohrbacher (April 2019)
Interview: Konstantina Giannioti, La Leche League International Leader
What can a mother do to ensure a good milk supply if she is exclusively breastfeeding or if she is exclusively pumping?
One way to ensure healthy milk production right after birth is to spend the first hour or two in skin-to-skin contact with the newborn and begin nursing as soon as the newborn makes his or her way to the breast and attaches. Skin-to-skin contact and early nursing helps prepare the mother’s body to produce abundant milk.
If a mother is exclusively breastfeeding, another important factor is to learn about normal newborn nursing patterns. Prepare for an intense experience during the first 40 days! Many mothers think that their newborns should be satisfied for hours after a feeding. They often don’t realize that clustering or bunching feeds together during some parts of the day is completely normal. By nursing whenever the baby seems interested (while making sure that totals to at least 8 to 12 times each day), the baby will ensure the mother makes plenty of milk. Being responsive to the baby’s desire to feed is critical. This is meant to be an automatic process driven by the baby. The mother doesn’t need to overthink it. She just needs to nurse whenever her baby is hungry.
When a mother is exclusively pumping (perhaps for a preterm baby), starting to pump within 1 hour of birth is key to good milk production. Research found that even weeks later, the mothers who began expressing their milk within that first hour after birth made much more milk than mothers who started pumping later. Another vital factor especially during the first two weeks after birth is pumping at least 8-10 times each day. That’s similar to what a baby would do to establish a good milk supply. Using your hands as well as the pump helps, too. In addition to pumping enough times each day, it helps for the mother to drain her breasts as fully as possible each time. There’s a technique called “hands-on pumping,” which involves the mother using her hands to do massage before pumping, then double-pumping (both breasts at once) for about 15 minutes, doing more massage, and then finishing by focusing on one breast at a time and either hand-expressing milk or single pumping with lots of massage and compression. By going back and forth from breast to breast this way while using her hands, mothers averaged about 50% more milk as compared with the mothers who used the pump alone.
Ref. Morton, J., et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009; 29(11): 757-764.
How can a breastfeeding mother protect her milk supply, if she needs to return to work soon after her baby is born?
Every mother has what I call her “Magic Number.” This refers to the number of milk removals (breastfeeds plus pump sessions) per day needed to keep her milk production steady. An average “Magic Number” is seven. But for some mothers, their milk production stays steady at more and some at less. Continuing to breastfeed often when she is with her baby makes a huge difference, too. That makes it easier to reach that “Magic Number” every day without having to pump as often at work. Many mothers mistakenly assume that breastfed babies are like formula-fed babies in terms of needing fewer feeds per day as they get older. Research shows that while formula-fed babies take fewer and larger feeds as they grow, that’s not the case with nursing. With breastfed babies, the number of feeds baby needs each day does decrease slightly, but not by much, and the volume of milk baby takes at breast stays remarkably stable between one month and six months.
Ref.[1] Kent, J. C., Hepworth, A. R., Sherriff, J. L., Cox, D. B., Mitoulas, L. R., & Hartmann, P. E. Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation. Breastfeeding Medicine 2013; 8:401-407.
Ref.[2] Mohrbacher, N. The magic number and long-term milk production. Clinical Lactation 2011; 2(1):15-18.
What is “low milk supply” and how do we know if a mother’s milk supply is low?
Many mothers worry that they have “low milk supply” when they actually make plenty of milk. Often they worry because they aren’t familiar with breastfeeding norms. The best way to gauge good milk production is by baby’s weight gain. During the first 3 months or so, a daily weight gain of about 30 g is a guarantee that a mother is making enough milk. Don’t judge milk production by baby’s behavior. Some of the “false alarms” that cause mothers to worry about their milk production that are NOT indicators of low milk supply are:
• Baby has fussy times.
• Baby wants to feed very often or even constantly for part of the day (that’s how babies ensure mothers make enough milk).
• Baby wakes often at night to breastfeed.
• Mother is unable to express much milk (milk expression is a learned skill that takes practice to master).
• Mother does not leak milk.
• Mother’s breasts don’t feel as full as they once did (this is normal about three or four weeks after birth).
A mother should strongly consider seeking breastfeeding help if her baby is not gaining weight as expected, if a baby younger than 6 weeks is not passing stools, or if she is feeling very anxious about her baby’s milk intake.
Ref. Gallipeau, R., Dumas, L., & LePage, M. Perception of not having enugh milk and actual milk production of first-time breastfeeding mothers: Is there a difference? Breastfeeding Medicine 2017; 12:210-17.
Is it common for women to have low milk supply and what are the reasons for it?
It is not common for women to have low milk supply. But it can happen in some unusual situations. For example, a mother who had breast reduction surgery (parts of the breasts were surgically removed) needs to monitor her baby’s weight carefully, as some have trouble making enough milk. Women with low thyroid function often have difficulty producing enough milk. In this case, taking thyroid medication to bring thyroid level up to normal will help. Occasionally, a woman is born with breasts that don’t develop normally. They may be very widely spaced and have an usual tubular shape. But these are all exceptions to the rule. Until about 150 years ago, breastfeeding was necessary for human survival. We wouldn’t be faced with overpopulation today if breastfeeding was not a hardy process that nearly always works. Also, we assume that every other mammal in the world produces enough milk for their baby. Why should we be any different?
How can a mother increase her milk supply?
If a mother needs to increase her milk supply, the most effective way to do this is to increase the number of times each days the milk is removed well from her breasts by either breastfeeding or pumping. For most mothers, it takes more than eight milk removals per day to see an increase. The more milk removals per day, the faster milk production will increase. This is how mothers produce enough milk for twins and triplets. We even have one recorded case of a mother producing enough milk for her quadruplets. If the mother just keeps putting her babies to breast over and over, her body receives the signal to make more and more milk. Conversely, if a mother nurses less often and feeds formula, her body thinks the baby needs less milk.
Ref. Berlin, C.M. Exclusive breastfeeding of quadruplets. Breastfeeding Medicine 2007; 2(2):125-26.
How can nipple trauma be prevented?
For most mothers, nipple pain and trauma are caused by a shallow latch. That means the baby feeds with the nipple near the front of his mouth rather near the back. There is a place in baby’s mouth that I nicknamed, the “comfort zone.” It is near where the baby’s hard and soft palates meet. (You can find this area in your own mouth using your finger or tongue to feel where your palate turns from hard to soft.) If the baby latches deeply enough so that the nipple reaches the comfort zone, there is no friction or pressure on the nipple. This allows a mother to breastfeed long and often without getting sore, which is why mothers of multiples can breastfeed more than one baby without necessarily developing sore nipples .
Ref. Kent, J.C., Ashton, E., Hardwick, et al. Nipple pain in breastfeeding mothers: Incidence, causes, and treatments. Int J Environ Res Public Health 2015; 12: 12247-12263.
If nipple trauma has occurred, what can help the wound to heal faster?
One approach is to express a little milk onto the nipple and let it dry. Some mothers prefer to apply a little ultra-purified lanolin to the traumatized area to keep it moist between feeds. Some also find the lanolin soothing during the healing process. What’s most important, though, is to correct the cause of the trauma first. Then the nipples can heal even if the mother continues to breastfeed.
Ref. Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2
How long does it usually take for nipple trauma to get better after appropriate measures are taken and what should the mother do if the trauma doesn’t heal within that time or if it gets worse?
If a mother’s nipple trauma is not improving, it’s time to see a breastfeeding supporter to determine the cause. Even if the baby is latching deeply, there are sometimes other causes. For example, there can be variations in a baby’s anatomy, such as tongue tie, that can make nursing painful. Tongue tie is when tongue movements are restricted during feeds because the membrane that attaches baby’s tongue to floor of his mouth is restrictive. In this case, the membrane can be released for more comfortable nursing. Nearly always nipple trauma can be overcome. But sometimes mothers need help from breastfeeding specialists to make that happen. It’s important to know who can provide skilled breastfeeding help in your area.
Ref. Kent, J.C., Ashton, E., Hardwick, et al. Nipple pain in breastfeeding mothers: Incidence, causes, and treatments. Int J Environ Res Public Health 2015; 12: 12247-12263.
How does breastfeeding protect against obesity and metabolic disorders?
Breastfeeding cannot protect against metabolic disorders, which are genetic and present at birth. But there are many aspects of breastfeeding that protect against obesity.
First, breastfeeding teaches babies to self-regulate their milk intake. Our breasts do not have volume markers on them, so mothers are not tempted to coaxes babies to “finish” the breast, as often happens with a bottle. Research has linked bottle-feeding with overfeeding and greater weight gain during infancy, which is also associated with increased risk of childhood and adult obesity. During breastfeeding, milk flow alternates between fast and slow. During bottle-feeding, milk flow is always fast, so babies often overfeed. Research found that bottle-fed babies drink much more milk per feed and per day than breastfed babies, which leads to more cases of overweight and obesity.
Second, mother’s milk contains hormones and other ingredients that are missing from formula that help regulate babies’ appetite. The hormones that enhance healthy weight are leptin, adiponectin, and ghrelin. Many other components of human milk also enable babies to use the nutrients in mother’s milk more efficiently and to grow and develop in a healthier way.
Third, formula is much higher in protein than human milk, which is not a good thing. Too much protein during infancy was linked to overweight and obesity, as well as diabetes and heart problems later in life.
Ref.[1] Azad, M.B., Vehling, I., Chan, D., et al. Infant feeding and weight gain: Separating breast milk from breastfeeding and formula from food. Pediatrics 2018; 142(4) doi: 10.1542/peds.2018-1092.
Ref.[2] Escribano, J., Lugue, V., Ferre, N., Mendez-Riera, G., Koletzko, B. et al. Effect of protein intake and weight gain velocity on body fat mass at 6 months of age: The EU Childhood Obesity Programme. Int J Obes (Lond.) 2012; 36(4):548-53.
Ref.[3] Feldman-Winter, L., Burnham, L., Grossman, X., et al. Weight gain in the first week of life predicts overweight at 2 years: A prospective cohort study. Maternal and Child Nutrition 2018; 14(1).
Ref.[4] Horta, B. L., Loret de Mola, C., & Victora, C. G. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and meta-analysis. Acta Paediatr 2015; 104(467), 30-37.
If bottle-feeding a baby is unavoidable, how can overfeeding be prevented?
There’s a better alternative than tilting baby back and holding the bottle at a 45-degree angle. It’s called “paced bottle-feeding,” which slows the milk flow. This bottle-feeding technique involves sitting the baby in a more upright position and holding the bottle more horizontally. Touch baby’s lips with the bottle teat and wait for her to open and drawn in the teat. Once she starts feeding, after every few sucks, tilt the end of the bottle down to give her a breathing break. This mimics the ebb-and-flow of milk that occurs during breastfeeding and gives baby time to feel full before being overfed.
What would you suggest supporting a mother transitioning her baby to the breast? What if the baby is refusing the breast?
The most important aspect of helping the baby accept the breast is to keep any time at the breast happy. Often a mother is so motivated to nurse that she keeps trying to persuade the baby to nurse, even after the baby is upset. After many tries that end in crying, the baby begins to develop negative associations and begins crying as soon as the mother opens her shirt. So the first step is to stop any fighting at the breast.
Luckily, negative associations can be overcome. To create happy time at the breast, put the baby in skin-to-skin contact without pressure to breastfeed. That means undressing baby to her diaper and putting her chest against mother’s bare chest. The more time mother and baby spend like that, with lots of talking, looking into one another’s eyes, and cuddling, the better. This releases the hormones oxytocin, which makes babies more open to breastfeeding. Babies often begin to go to the breast on their own when in skin-to-skin contact.
Feeding position that work well for many babies transitioning to the breast are those in which the mother leans back into a semi-reclined position with baby tummy down on top of her. This works best if the mother leans back far enough so that baby is fully resting her on her body without her having to support baby’s weight in her arms. It is also best not to be flat on her back. Ideally, she’s elevated enough so that she can easily look into her baby’s eyes without straining her neck. You can watch a free video of mothers using these positions at www.NaturalBreastfeeding.com. These positions take advantage of the natural hardwiring that with which babies are born.
Ref.[1] Colson, S. D., J. H. Meek, et al. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev 2008; 84(7): 441-9.
Ref.[2] Svensson, K.E., Velandia, M.I., Matthiesen, A.-S., Welles-Nystrom, B.L., et al. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: A randomized trial. International Breastfeeding Journal 2013; 8:1.
Could you please share with us your story about how you became a La Leche League Leader and what inspired you to write books regarding breastfeeding?
When I was 5 months pregnant with my first baby, my husband Michael and I had just moved to a new city near Chicago. A friend in our previous city recommended I start attending LLL meetings after our move. I thought that would be a great place to meet women who were also having babies, and I absolutely loved the meetings! I had just “retired” from my paid job as an editorial assistant and was looking for a way to engage my mind while I stayed home to raise my child. My first LLL meeting was in June 1980, before the lactation profession existed. It seemed obvious to me that there was a great need for breastfeeding support, so after my baby was born and we figured out nursing, I decided to become an LLL Leader to help support other women. My LLL co-Leader was Julie Stock, who worked at the nearby LLL International Office as head of the reference library (the precursor to what was later its Center for Breastfeeding Information). Julie got me involved in editing LLL’s publication for parents, New Beginnings, and then I started writing books for LLLI. Becoming a breastfeeding author and speaker has led to wonderful experiences. In my international travels, I have made many friends and met many remarkable people doing amazing work to support breastfeeding. I feel very lucking, because I now have many “sisters in lactation” all around the world.
Nancy Mohrbacher, IBCLC, FILCA began helping families in 1982 as a volunteer breastfeeding counselor. She became a board-certified lactation consultant in 1991 and spent 10 years growing a large private lactation practice in the Chicago area, where she worked one-on-one with thousands of families. Mohrbacher has three current breastfeeding books for families and two for professionals, including her comprehensive, evidence-based-based counseling guide, Breastfeeding Answers Made Simple (see more information at http://www.nancymohrbacher.com/). Her Breastfeeding Solutions app is used worldwide and her YouTube channel https://www.youtube.com/user/NancyMohrbacher has more than 1.3 million views. Mohrbacher currently contracts with hospitals to improve breastfeeding practices, writes for many publications, and speaks at events around the world.
She was in the first group of 16 to be honored for her contributions to breastfeeding with the designation FILCA, Fellow of the International Lactation Consultant Association.
