BookRitchieJennifer

I make milk.
What’s your superpower?
The Ultimate Breastfeeding Guide
Jennifer Ritchie, IBCLC
International Board Certified
Lactation Consultant

Table of Contents
Introduction
The Barriers to Breastfeeding
How Long Should a Woman Breastfeed?
What is all of the hype on breastfeeding anyway?
The History of Infant Formula
The International Code of Marketing of Breastmilk Substitutes
The Baby Friendly Hospital Initiative
The Affordable Care Act - Breastfeeding Services Are Covered By Insurance!
The Benefits of Breastfeeding for Mom and Baby
Breastfeeding 101 / What You Really Need To Know
Preparation While You Are Pregnant
The First Stage of Lactation (Colostrum is Liquid Gold)
The Pamela Anderson Phase! The Second Stage of Lactation
Infant States Proven By Research
The Crucial First 2 Weeks
Establishing A Milk Supply
The Breastfeeding Hormones - Oxytocin and Prolactin
Positioning and Latch – The Fundamentals of Breastfeeding...
Nipple Shields

Tongue Tie
How To Supplement on the Breast
Jaundice
How Often Should I Be Breastfeeding
Fussy Baby
Food Protein Intolerance and Lactose Intolerance59
Acid Reflux
Burping
Pulling Off of the Breast / Biting
Engorgement
Increasing Milk Supply
Reducing Milk Supply
Plugged Ducts
Mastits
Therapeutic Ultrasound to treat Engorgement, Plugged Ducts and Mastits
Oversupply Syndrome / Foremilk Hindmilk Imbalance
Nipple Vasospasm / Reynaud’s
Bacterial Infection of the Nipples
Thrush
Breastfeeding Twins

Worksheets:
Baby Feeding Requirements Chart
Breastfeeding Log
Baby Friendly Designated Facilities as of November 2012

Introduction
After writing an online article for a magazine about breastfeeding, a reader
posted the following comment; “A breastfeeding class, are you kidding me?
That is like teaching a class to guys on how to drink beer!” Annoyed as I was
at first to read this post, I realized that it did make sense. Why would anyone
need a Lactation Consultant to help with something that should come so
naturally?
Let me tell you a little about what a Lactation Consultant does. Just as a
woodworker uses many tools and techniques to craft a piece of furniture, a
Lactation Consultant crafts a breastfeeding plan to help your baby thrive, to
eliminate any pain or anxiety, and to be there for you to answer all of your
breastfeeding questions. My name is Jennifer Ritchie, and I am going to be
your new best friend for the next year.
Since you are my new BFF, let me tell you a little about myself. I am a full
time working mom, a wife, an Internationally Board Certified Lactation
Consultant, and the owner of an amazing Breastfeeding Boutique located in
Southern California named Milkalicious. After opening Milkalicious 4 years
ago, I have personally helped over 3,000 new mothers successfully breastfeed.
This is a picture of me a week before giving birth to my son, and me now.
Yes, that is an extra large maternity tank top I was wearing, and it doesn’t even
fit over my stomach! I stopped looking at the scale after gaining 70 lbs with
both my pregnancies, because I was either eating or nauseous. Do not show

anyone this picture of me :)
I had been pushing 200lbs and I am only 5’4, I have been sleep deprived, and
somehow stayed married after having a colicky baby. I have suffered from
plugged ducts, had mastitis more than 8 times, many cases of thrush, and dealt
with low milk supply. With all of that, I managed to breastfeed for more than 5
years between both of my kids. Why? Because after completing over 1,000
hours of education, SPECIFICALLY in the area of lactation, I now had the
knowledge on how to fix each problem. Now, I want to pass this knowledge
along to you.
Let me tell you about the way that I work. I breastfed for a long, long time, but
this book is not about me. I have my own parenting style, and my own
experiences. What does matter is the evidence, and developing a plan that will
work for you and your lifestyle. Unlike some Lactation Consultants, I am 100%
evidence-based, and every bit of information you will find in this book is
based on published research studies from around the world. Helping moms and
babies is what I do all day, every day, and I’m simply here to provide you with
information so you can be successful at breastfeeding.
I didn’t start out my career wanting to be a lactation consultant; it a path I
chose in hopes of changing the world. I chose this career after falling IN LOVE
with breastfeeding, and I hope you fall in love with breastfeeding too.
Why every pregnant or nursing mom HAS to have this book
Finding answers to your breastfeeding questions can be frustrating to say the
least. When you look online, less than half of the websites that contain
breastfeeding information are accurate. Instead you can refer to this book
whenever you have a question; it is your Lactation Consultant in a cute little
package.
Regardless if you are having problems now, or if you are simply gaining
knowledge of potential breastfeeding pitfalls, this is the book for you. We will
talk about what to expect from breastfeeding, and what to do if issues arise.
The great thing about breastfeeding is that there is a solution to almost every
problem. In most cases we can trick the body into doing what we want it to do,
and we can observe our babies behavior to give us insight on what the problem

is.
To breastfeed, you have to have lots of support! You will need the support of
your family, significant other, your OBGYN and your pediatrician. Just be
prepared, sometimes your doctor may not know all the answers. It’s not their
fault; they don’t receive enough breastfeeding education in Medical School.
The great thing is that each study that is referenced in this book is listed, so you
can always print out the study to share with your doctor.

It can be harder than you think!
Chapter 1
The Barriers Of Breastfeeding
#1: Most breastfeeding problems occur in the first two weeks of a child’s life,
so lots of new moms just throw in the towel. That’s why your focus in the
beginning is to just make it past the first 2 weeks.
#2: There is a chance you will not make enough milk to completely feed your
baby with breast milk alone. This is also a big reason why new moms give up
breastfeeding altogether. If you have to supplement with some formula, that is
okay! DO NOT beat yourself up about it, and do not give up. One drop of
breastmilk contains one million white blood cells; so some is better than
none. If you don’t make enough milk, if you need to go back to work at 6
weeks and can’t afford a pump, or if you are just too overwhelmed, that’s ok!
If your baby gets at least 1 teaspoon of breastmilk per day, your baby will be
protected with the antibodies and those bacteria-eating cells that are so
important to a developing immune system.
Pretend you just qualified to be in the Breastfeeding Olympics, and you have
some fierce competition. Instead of other athletes, your competition is
hormonal imbalances, breast anatomy, insufficient milk removal, yeast,
bacteria, and good old-fashioned pain.
I am not telling you to go to the store and stock up on formula, I just want you
to go into this challenge with determination, but knowing that you may have
some setbacks. Just because you get knocked down doesn’t mean you have to
give up, ladies!

It also doesn’t help that we have the worst paid maternity leave. Nope, you
didn’t miss the US, we are that tiny speck at the very bottom :(

But
Chapter 2
How Long Should a Woman Breastfeed?
• The American Academy of Pediatrics (AAP) and the American
Association of Family Physicians (AAFP) recommend that: Babies
receive nothing but breast milk for about the first 6 months of life; and
Mothers continue breastfeeding at least until the end of a baby’s first year.
• The World Heath Organization Recommends: Exclusive breastfeeding is
recommended up to 6 months of age, with continued breastfeeding along
with appropriate complementary foods up to two years of age or beyond.
Believe it or not, the world average for weaning is age 5, so you can see why
we get so much pressure to breastfeed. Our country is far behind most in
breastfeeding rates, but we also have little support. According to the 2012
“Save the Children” Scorecard, Malawi (this little country in Africa) is
providing better nutrition to their babies than we are!
Within an hour after birth, 95 percent of babies in Malawi are put to the breast.
At 6 months, 71 percent are still being exclusively breastfed, and between 6-9
months, 87 percent are breastfed with complementary foods. At age 2, 77
percent of children are still getting some of their nutrition from breast milk.
Why? All medical care in Malawi is free. In Sweden a new mom can call a
lactation consultant whenever they want for free, or do a consultation for $10.

At Milkalicious, my own practice in California, I have to charge $85 to meet
with a new mom, just to cover the order minimums required by the pump
companies to stock the supplies I need, and to keep my doors open. With no
breastfeeding outpatient support available from the government, and the limited
financial resources available to small businesses, the only lactation consultants
you will typically meet are in the hospital. If you have a vaginal birth, you are
discharged in 2 days. Typically, this is before your milk “comes in” so you
will be stuck without resources when you need them the most. Many new moms
find themselves on the Internet at 2 am looking up symptoms and selfdiagnosing.
Why are breastfeeding rates in the US so low?
Studies show that although over 80% of women start breastfeeding in the
hospital, only 12% of babies in the US are getting any breastmilk at 6
months of age.
Based on my patients’ feedback, the decline is not due to lack of effort but the
anxiety caused by breastfeeding problems or the concern that the baby is not
getting enough. Most of the 3,000+ patients I have seen have told me they

would have given up if it weren’t for the help they received from Milkalicious.
References:
1. State of the World’s Mothers 2012: Save the Children, May 2012.
2. Breastfeeding Report Card—United States, 2012: Centers for Disease Control and Prevention (CDC)

Chapter 3
What is all of the hype on breastfeeding anyway?
Is breastmilk really that different from formula? Really, the only thing
breastmilk and formula have in common is they’re both fed to babies. The
infant formula industry is big business, and they do a VERY good job of
convincing us that it is similar to breastmilk. But breastmilk is alive, and
formula is dead watered-down cow’s milk with added sugar, plain and simple.
To put it into perspective
“for every $1 spent by the World Health
Organization on preventing the diseases caused
by infant formula, more than $500 is spent by
the food industry to promote it”
You need to be a knowledgeable consumer, so the following chapters have
some info on why infant formula is so readily available in the US.
For all of you out there who love gossip: the rise of the formula industry is as
interesting as the rise of the Kennedy family. The companies that own the top
three infant formulas are very powerful, very smart, and they have the right
friends in the right places.
References:
1. Nutritional considerations in infant formula design. Seminars in Fetal & Neonatal Medicine, 1(1): 19-26
(February 1996).
2. Fomon, Samuel J. (2001). “Infant Feeding in the 20th Century: Formula and Beikost”. San Diego, CA:
Department of Pediatrics, College of Medicine, University of lowa. Retrieved September 16, 2006.
3. World Health Organization. Global strategy for infant and young child Geneva, 2003. Retrieved August
8, 2011.
4. Committee on the Evaluation of the Addition of Ingredients New to Infant Formula (2004). Infant
Formula: Evaluating the Safety of New Ingredients. The National Academies Press. Retrieved September
16, 2006.

Chapter 4
The History of Infant Formula
Throughout history, mothers who could not breastfeed employed a wet nurse.
From the end of the 18th century through the 19th century, the practice of wet
nursing shifted away from wealthy families to laboring, lower-income
families. In the 19th century, artificial feeding became a feasible substitute for
wet nursing. Advancement in the feeding bottle and the availability of animal’s
milk began to slowly, but steadily, affect the use of wet nurses. By 1900, the
once highly organized wet-nursing profession was extinct.
Homemade formulas were more commonly used than commercial formulas: a
mixture of cow’s milk, water, cream, and sugar or honey. These formula-fed
babies exhibited more diet-associated medical problems, such as scurvy,
rickets and bacterial infections, than breastfed babies.
In the 1920s and 1930s, evaporated milk began to be widely available at low
prices, and became the #1 ingredient in homemade infant formula. At the same
time period, two commercial formulas were released: Similac (“similar to
lactation”), and Sobee (with protein from soybean flour). Several other
formulas were released over the next few decades, but commercial formulas
did not begin to seriously compete with evaporated milk homemade formulas
until the 1950s.
The reformulation and concentration of Similac in 1951, and the introduction
of Enfamil in 1959 were accompanied by marketing campaigns that provided
free formula to hospitals and pediatricians. By the early 1960s, commercial
formulas were more commonly used than evaporated milk formulas in the
United States, which all but vanished in the 1970s. By the early 1970s, over
75% of American babies were fed on formulas, almost entirely commercially
produced.
Breastfeeding resurged at the end of the Second Millennium. The amount of
new mom’s in the US that put the baby to the breast in the hospital in 1950 was
25%. By 1975, that number began to increase, from 25% to 33.4%, to a
dramatic 54% in 1980. More women breastfeeding = Loss in revenue
for the formula companies.

Historically, infant formula has been made and marketed by pharmaceutical
companies, and if you know any pharmaceutical reps, you know their approach
to marketing is based on ’’medical detailing.’’ This is the practice of
contacting hospitals and medical practitioners directly, providing them with
free or discounted products, and encouraging health workers to recommend
their brands. This method of marketing is quite expensive and the
manufacturers of infant formula saw that a government nutrition assistance
program could fulfill the same functions at much lower cost.
More than half the infant formula used in the United States is provided to
mothers at no cost through the federal government’s Special Supplemental
Nutrition Program commonly known as WIC. The Food and Nutrition Service
of the USDA administer the WIC program, launched in 1974. The formula
companies were among the strongest advocates for the creation of the WIC
program in the US. As Cynthia Tuttle put it, ’’the establishment of the WIC
program provided formula manufacturers with a new, very direct avenue of
marketing to one of their target audiences, and they were quick to take
advantage of this opportunity.’’
In the early 1980s, many WIC offices purchased infant formula at full retail
prices. As the cost of formula rose, formula accounted for nearly 40 % of total
WIC food costs so WIC began to explore ways to limit its formula costs. The
competitive bidding began! The formula companies agreed to give back
“rebates” to WIC for the purchase of formula so they would continue to
purchase it.
In fiscal year 2004, the WIC program had 7 million participants and program
costs were $4.9 billion dollars. Rebates provided about $1.5 billion back to
WIC. From the formula companies’ perspective, WIC has become an effective
marketing tool, and the expanded reach has helped to get more infants started
on formula.
In the year 2000, just three companies accounted for 99 % of the infant formula
market in the US: Mead Johnson-52 %; Ross-35 %, and Carnation-12 %. Each
of them is a subsidiary of a larger company:
• Mead Johnson, maker of Enfamil and Gerber infant formula, is part of
Bristol-Myers Squibb. Their 2012 Marketing budget is $560 million (not

including rebates to WIC).
• Ross Laboratories, maker of Similac infant formula, is a division of Abbott
Laboratories. Abbott’s annual research and development budget exceeds $1
billion (not including rebates to WIC).
• Carnation, maker of Good Start infant formula, has been a subsidiary of
Nestlé (based in Switzerland) since Nestlé purchased it in 1988.
The average percentage discount (i.e., the rebate as a percentage of the
wholesale price) in the previous WIC contracts with Nestlé was 91%. In other
words, WIC on average paid only 9% of the wholesale price for formula (plus
the retailer’s markup).
References:
1. Tuttle CR: An open letter to the WIC program: The time has come to commit to breastfeeding. J Hum
Lact 2000, 16:99-103.
2. Black RE, Morris SS, Bryce J: Where and why are 10 million children dying every year? Lancet 2003,
361:2226-2234.
3. Caulfield LE, de Onis M, Blossner M, Black RE: Undernutrition as an underlying cause of child deaths
associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2004, 80:193-198.
4. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, Fuchs SC, Moreira LB,
Gigante LP, Barros FC: Infant feeding and deaths due to diarrhea. A case-control study. Am J Epidemiol
1989, 129:1032-1041.
5. Lawrence RA: A Review of the Medical Benefits and Contraindications to
Breastfeeding in the United States Arlington, VA: National Center for Education in Maternal and Child
Health]; 1997.
6. Oddy WH: The impact of breastmilk on infant and child health. Breastfeed Rev 2002, 10:5-18.
7. Wolf JH: Low breastfeeding rates and public health in the United States. Am J Public Health 2003,
93:2000-2010.
8. Labbok MH, Clark D, Goldman AS: Breastfeeding: maintaining an irreplaceable immunological
resource. Nat Rev Immunol 2004, 4:565-572.
9. León-Cava NC, Lutter JR, Martin L: Quantifying the Benefits of Breastfeeding: A Summary of the
Evidence Washington, D.C.: Pan American Health Organization; 2004.
10. Fewtrell MS: The long-term benefits of having been breastfed. Current Paediatrics 2004, 14:97-103.

11. Breastfeeding Could Save 1.3 Million Infants Each Year
[http://www.unicef.org/nutrition/index_22657.html]
12. Chen A, Rogan WJ: Breastfeeding and the risk of postneonatal death in the United States. Pediatrics
2004, 113:e435-439.
13. Nommsen-Rivers LA: Does breastfeeding protect against infant mortality in the United States? J Hum
Lact 2004, 20:357-358.
14. Breastfeeding. Best for Baby, Best for Mom
[http://www.4woman.gov/Breastfeeding/Breastfeeding.pdf]
15. American Dietetic Association: Position of the American Dietetic Association: Breaking the Barriers
to Breastfeeding. J Am Diet Assoc 2001, 101:1213-20.
16. Weimer JP: The Economic Benefits of Breastfeeding: A Review and Analysis. Wahington, D.C.: U.S.
Dept. of Agriculture, Economic Research Service; 2001.
17. Global Strategy for Infant and Young Child Feeding Geneva: World Health Organization; 2003.
18. American Academy of Pediatrics: Breastfeeding and the use of human milk. Pediatrics 2005, 115:496-
506.
19. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) [http://
www.fns.usda.gov/wic/aboutwic]
20. WIC Program Participation and Costs Washington, D.C.: Food and Nutrition Service, United States
Department of Agriculture; 2005.
21. WIC Food Package: What are the Federal Regulatory Requirements for WIC-eligible Foods? Food
and Nutrition Service. United States Department of Agriculture; 2004.
22. Kramer-LeBlanc CS, Mardis A, Gerrior S, Gaston N: Review of the Nutritional Status of WIC
Participants. Washington, D.C.: Center for Nutrition Policy and Promotion, United States Department of
Agriculture; 1999.
23. Oliveira V, Prell M: Sharing the economic burden: Who pays for WIC’s infant formula? Amber
Waves 2004, 2:30-36.
24. United States. General Accounting Office. United States. Congress. House. Committee on the
Budget: Food Assistance: Information on WIC Sole-source Rebates and Infant Formula Prices: Report to
the Chairman, Committee on the Budget, House of Representatives Washington, D.C.; 1998.
25. Richter J: Holding Corporations Accountable: Corporate Conduct, International Codes, and Citizen
Action London and New York: Zed Books; 2001.
26. Senate rpt. 108-279- Vendor Cost Containment, The Child Nutrition and WIC Reauthorization Act of
2004 [http://tho mas.loc.gov/cgi-bin/ cpquer?&db_id=cp108&r_n=sr279.108&sel=TOC_165376&]
27. Sokol E: The Code Handbook: A Guide to Implementing the International Code of Marketing of

Breastmilk Substitutes Penang, Malaysia: International Baby Food Action Network; International Code
Documentation Centre; 1997.
28. Besharov DJ, Germanis P: Evaluating WIC. Eval Rev 2000, 24:123-190.
29. Oliveira V, Prell M, Smallwood D, Frazao E: Infant Formula Prices and Availability: Final Report to
Congress. Washington, D.C.: Economic Research Service, United States Department of Agriculture;
2001.
30. Bristol-Myers Squibb website [http://www.bms.comproducts/data/]
31. Abbott website [http://www.abbott.com]
32. Carnation/Nestle website
33. Ryan AS, Zhou W: Lower breastfeeding rates persist among the Special Supplemental Nutrition
Program for Women, Infants, and Children participants, 1978-2003. Pediatrics 2006, 117:1136-1146.
34. Lawrence RA: Lower breastfeeding rates among supplemental nutrition program for women, infants,
and children participants: a call for action. Pediatrics 2006, 117:1432-1433.
35. Ross Laboratories: Mothers Survey, Ross Products Division of Abbott, 2004, Appendix 1.
36. United States. General Accountability Office: Breastfeeding: Some Strategies Used to Market Infant
Formula May Discourage Breastfeeding: State Contracts Should Better Protect against Misuse of WIC
Name. Washington, D.C.; 2006.
37. Racial and socioeconomic disparities in breastfeeding- United States, 2004. MMWR Morb Mortal
Wkly Rep 2006, 55:335-339.
38. Breastfeeding Intervention Design Study. Washington, D.C.: Food and Nutrition Service. United States
Department of Agriculture; 2004.
39. United States General Accountability Office: Breastfeeding: Some Strategies Used to Market Infant
Formula May Discourage Breastfeeding: State Contracts Should Better Protect against Misuse of WIC
Name Washington, D.C.; 2006.
40. Innocenti Declaration
[http://www.unicef.org/programme/breastfeeding/innocenti.htm]
41. United Nation’s Children Fund: 1990-2005: Celebrating the Declaration on the Protection, Promotion
and Support of Breastfeeding: Past Achievements, Present Challenges and the Way Forward for Infant
and Young Child Feeding.
New York: UNICEF.
42. IBFAN: International Code of Marketing of Breast-milk Substitutes. International Baby Food Action
Network 2006.
43. Shubber S: The International code of marketing of breast-milk substitutes an international measure to

protect and promote breastfeeding The Hague; Boston: Kluwer Law International; 1998.
44. World Health Organization: International Code of Marketing of Breastmilk Substitutes Geneva; 1981.
45. United States. Dept. of Health and Human Services. Office on Women’s Health: Breastfeeding: HHS
Blueprint for Action on Breastfeeding Washington, D.C.; 2000.
46. Convention on the Rights of the Child [http://www.ohchr.org/english/law/crc.htm]
47. International Covenant on Economic, Social and Cultural Rights [http://www.ohchr.org/
english/law/cescr.htm]
48. Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social
and Cultural Rights: General Comment 12 (Twentieth Session, 1999)
49. Infant Formula: Meeting Report. Geneva, Switzerland: World Health Organization; 2004.
50. A History of Infant Feeding Emily E Stevens RN, FNP, WHNP, PhD, Thelma E Patrick RN, PhD,
and Rita Pickler RN, PNP, PhD
51. USDA website: www.fns.usda.gov/wic/faqs/faq.htm

Chapter 5
The International Code of Marketing of Breastmilk
Substitutes
When it became clear that declining breastfeeding rates were affecting infant
health and that the advertising and availability of infant formula had a direct
effect on a woman’s decision not to breastfeed, the International Code of
Marketing of Breastmilk Substitutes was drafted and eventually adopted by the
World Health Assembly (WHA) in 1981.
Specifically, the Code:
* Bans all advertising or promotion of infant formula to the general public
* Bans samples and gifts of infant formula to mothers and health workers
* Bans the use of the healthcare system to promote infant formula
* Bans free or low-cost supplies of infant formula
* Allows a health professional to receive samples, but only for research
purposes
* Bans sales incentives for of infant formula and direct contact with mothers
* Requires that labels inform fully on the correct use of infant formula and the
risks of misuse
* Requires labels not to discourage breastfeeding
As you read this, you have probably quickly figured out that the wonderful
United States does not follow the code. The only countries in the ENTIRE
WORLD that have not made any efforts to follow the code are Somalia, Chad,
Iceland, Kazakhstan, and the United States.
References:
World Health Organization. International Code of Marketing of Breast-milk Substitutes.

Geneva, 1981.

Chapter 6
The Baby Friendly Hospital Initiative
We are making progress in the US thanks to the Baby-Friendly Hospital
Initiative. The BFHI is a global program that was launched by the World
Health Organization (WHO) and the United Nations Children’s Fund
(UNICEF) in 1991 to encourage and recognize hospitals and birthing centers
that offer an optimal level of care for infant feeding and mother/baby bonding.
It recognizes and awards birthing facilities that successfully implement the Ten
Steps to Successful Breastfeeding and the International Code of Marketing of
Breast-milk Substitutes. The BFHI assists hospitals in giving all mothers the
information, confidence, and skills necessary to successfully initiate and
continue breastfeeding their babies or feeding formula safely, and gives
special recognition to hospitals that have done so.
A maternity facility can be designated ’baby-friendly’ when it does not accept
free or low-cost breastmilk substitutes, feeding bottles or pacifiers, and has
implemented 10 specific steps to support successful breastfeeding. The
process is currently controlled by national breastfeeding authorities and
developed by UNICEF and The World Heath Organization. If you want to see
a list of Baby Friendly Hospitals, it is at the back of the book. If you live close
to any of these hospitals, this is where you want to go to have your baby.

Chapter 7
The Affordable Care Act - Breastfeeding Services Are Now
Covered By Insurance!
The Affordable Care Act – the health insurance reform legislation passed by
Congress and signed into law by President Obama on March 23, 2010 – helps
make prevention affordable and accessible for all Americans by requiring
health plans to cover preventive services and by eliminating cost sharing.
Preventive services that have strong scientific evidence of their health benefits
must be covered and plans can no longer charge a patient a copayment,
coinsurance or deductible for these services when a network provider delivers
them.
Women’s Preventive Services: Required Health Plan Coverage Guidelines
Supported by the Health Resources and Services Administration: Under the
Affordable Care Act, women’s preventive health care – such as mammograms,
screenings for cervical cancer, prenatal care, and other services – is covered
with no cost sharing for new health plans. However, the law recognizes and
HHS understands the need to take into account the unique health needs of
women throughout their lifespan.
The HRSA-supported health plan coverage guidelines, developed by the
Institute of Medicine (IOM), will help ensure that women receive a
comprehensive set of preventive services without having to pay a co-payment,
co-insurance or a deductible. HHS commissioned an IOM study to review
what preventive services are necessary for women’s health and well being and
should be considered in the development of comprehensive guidelines for
preventive services for women. HRSA is supporting the IOM’s
recommendations on preventive services that address health needs specific to
women and fill gaps in existing guidelines.
Health Resources and Services Administration Supported Women’s
Preventive Services: Required Health Plan Coverage Guidelines
Type of
Preventive
HHS Guideline for Health Insurance
Frequency

Service
Breastfeeding
support, supplies,
and counseling.
Coverage
Comprehensive- lactation support and
counseling, by a trained provider during
pregnancy and/or in the postpartum period,
and costs for renting breastfeeding
equipment.
In
conjunction
with each
birth.
Screening and
counseling for
Interpersonal and
domestic
violence.
Screening and counseling for interpersonal
and domestic violence.
Annual.
What does this mean for you? If you search out a DME (Durable Medical
Equipment Provider) or a Lactation Consultant that works with insurance
companies (in-network) some if not all of the cost for breastfeeding equipment
(breast pump, etc.) would be covered by your “medical insurance” if
medically necessary.

Chapter 8
The Benefits of Breastfeeding for Mom and Baby
You were formula fed and you turned out just fine! It is true, you can turn out
just fine being 100% formula fed, and humans do, get antibodies from the
placenta (unlike other mammals), but here is just a little more info on the host
of ingredients that breastmilk is made up of:
For every 1,000 babies not breastfed, there are an extra 2,033 physician visits,
212 days in the hospital and 609 prescriptions. One large study by the National
Institute of Environmental Health Sciences showed that children who are
breastfed have a 20 percent lower risk of dying between the ages of 28 days
and 1 year than children who weren’t breastfed, with longer breastfeeding
associated with lower risk.

Each drop of breastmilk contains 1 million white blood cells.
These are the cells that KILL bacteria, fight infection, fight disease, and
destroy old or damaged cells in the body. Not only that, the breastmilk contains
antibodies that binds to microorganisms and keep them away from the body’s
tissues. The main immune factor at work here is a substance called secretory
immunoglobulin A (IgA) that repels invading germs by forming a protective
layer on the mucous membranes in your baby’s intestines, nose, and throat.
When an infant is exposed to a germ, the mother is often exposed to the same
germ. But in the first six to nine months of life, the infant’s ability to make
antibodies to fight that germ is limited, so the mother makes these germ fighters
for her baby. These antibodies travel to her milk and are delivered to her baby.

Even when a baby contracts a germ, say at day care, the baby “exposes”
mother’s breasts to that germ through sucking, and within eight hours the
breasts are able to make antibodies to that germ and offer them to the baby via
the milk.
That’s leads to less meningitis, stomach viruses, ear infections, asthma,
juvenile diabetes, sudden infant death syndrome, type 1 and type two diabetes,
high cholesterol, high blood pressure, Crohn’s disease, ulcerative colitis,
inflammatory bowel disease and even childhood leukemia.
In 2009 Scientists at Queen Mary, University of London discovered that an
ingredient in human breast milk protects and repairs the delicate intestines of
newborn babies. Pancreatic secretory trypsin inhibitor, or PSTI, is found at its
highest levels in colostrum. In their research, when they inflicted damage to
cells in the intestines, they found that PSTI stimulated the cells to move across
the damaged area forming a natural protective ’plaster’. They also found that
PSTI could prevent further damage by stopping the cells of the intestine from
self-destructing.
For those of you that want your taxes lowered, a 2010 cost analysis was
published in Pediatrics that the US government would save $13 billion per
year if 90% of U.S. women breast-fed their babies for the first six months of
life.
If that’s not enough, here is the icing on the cake. It also increases their IQ!
Children breast-fed longer than six months scored a 3.8-point IQ margin over
those who were bottle-fed, according to a seven-year study by researchers at
Jagiellonian University Medical College in Poland. My professor at UC San
Diego, the most amazing Lactation Consultant on the planet, told me a story
about a nurse that made a point to tell her in a snotty tone that her son was not
breastfed, and he went to Stanford! Although she smiled and said how great
that was, all she wanted to say was “if you would of breastfed, he would have
gone to Stanford for FREE!” ha ha.
Benefits for Mom! Whaaaat? There are benefits for the mom, you betcha!
Breastfeeding reduces the risk of breast cancer by as much as 25 percent, it
reduces the risk of uterine and ovarian cancer, osteoporosis, aortic
calcification, strokes, hypertension, heart attacks and other cardiovascular

complications. It reduces postpartum anxiety and depression, it saves money
and creates less waste (for those of you that want to be Green!) and blood
pressure is “significantly higher” in mothers who had not breastfed.
If that is not enough to convince you, breastfeeding burns 480 to 1,000 calories
per day. Do you know how much cardio you would have to do a day to burn
this much ladies!!! The fat that tends to accumulate during pregnancy is in part
visceral fat, which sits around organs in the midsection and can put people
more at risk for heart and other types of diseases. A recent study found that of
the 351 women aged 45 to 58; those who had children and not breastfed had 28
percent more visceral fat than those who had consistently breastfed. You can
say goodbye to that muffin top!
References:
1. Duration of lactation and risk factors for maternal cardiovascular disease. Schwarz EB, Ray RM,
Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA
2. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Bartick M,
Reinhold A
3. Current Research Continues to Support Breastfeeding Benefits Mary Lou Moore, PhD, RNC, LCCE,
FACCE, FAAN
4. The Benefits of Breastfeeding: An Introduction for Health Educators Sheila G. J. Clark and Timothy J.
Bungum

Chapter 9
Breastfeeding 101 / What You Really Need To Know
Congratulations! You have made the decision to breastfeed your baby! Now I
want you to raise your right hand and repeat after me:
• I will do the best I can
• I will not feel any guilt if this doesn’t work out
• I am going to tell my friends and family to support me in my choice to
breastfeed
• I am going to work hard to provide the best start for my baby
• I am awesome, super smart, and look like a supermodel :)
The most important influence on your decision to breastfeed is your husband or
partner, your family and your friends. If they haven’t breastfed, they will not
understand. You need to trust your instincts and look at the research. It’s that
simple.
I recently read an article with Katie Couric that said, “life is a bunch of
reboots”. That is very true in day-to-day life, but having a baby is like a
complete system overhaul. It’s like switching from a Mac computer to a DOS
system. Everything you think you know goes right out the window. You can’t
imagine how much you will do on practically no sleep, how the color and
frequency of poop will consume your day, and how you can love this little
person 10,000 times more than anyone or anything on the planet.
We all know breastfeeding is best, and we all want to give our babies the best
possible start BUT...if you have cracked, sore, bleeding nipples, a breast
infection, or a screaming baby, it’s going to be hard to make it work. What you
need to have is SERIOUS determination. We are talking “girl is going after
your boyfriend” type of determination. It isn’t going to be easy, but it will be
worth it! You will be doing what your body was designed to do, and provide
the perfect food for your baby. What could be better than that?

You Will Need To Learn How To Handle Unwanted Advice
Make it a game with your husband, partner, or beast friend. Every time
someone tells you to do something that goes against what the research shows,
you can have a phrase ready to say. For example: “WOW, I had no idea! I’m
definitely going to do that right away”. Get ready to say that phrase a lot!
For example, your mother in law tells you to stop eating broccoli because it is
making the baby gassy, or that babies should be sleeping through the night at 3
weeks, or you have to drink milk in order to make milk (these are all
breastfeeding myths by the way), just smile and say, “WOW, I had no idea!”

Chapter 10
Preparation While You Are Pregnant
There are lots of things that we can do while you are still pregnant. We can
prepare for boosting milk supply based on your medical history, or put a tool
or two in your hospital bag just in case. Breastfeeding is physical and
hormonal, so there is a checklist you can go through while you’re pregnant to
see if you have any precursors for low milk supply.
1. Did you have trouble getting pregnant?
2. Do you have thyroid issues?
3. Do you have diabetes?
4. Do you have Poly Cystic Ovarian Syndrome?
5. Did your breasts change size during pregnancy?
6. Have you had a breast surgery?
#5 is an important question: Did you experience breast changes during
pregnancy. Sometimes you need to ask her significant other to answer that one.
I’m not talking Dolly Parton changes, just slight changes in your bra cup size.
About 1.5% of women do not have enough mammary tissue to make milk, so
we must consider this as a possibility.
If you have any history of thyroid issues, diabetes, polycystic ovarian
syndrome, or you had problems getting pregnant; these are all precursors for
low milk supply. Don’t worry, we can work on synthetically boosting your
prolactin after the baby is born, but just knowing this information will help.
You can refer to the section titled “Increasing Your Milk Supply.”
Look At Your Nipples
When I work with a pregnant mom, I do a breast exam to see if I can find any
potential issues with the latch. If the nipples are flat or retract upon
compression, we can plan for the use of a nipple shield. We go into detail

about nipple shields in a later chapter. To see if your nipples retract upon
compression, simply squeeze your areola from both sides and see what your
nipple does. If it stays in place, you are in good shape. If it retracts back into
the boob, you will want to be prepared for a possible latch issue. Don’t worry,
you found out before any issues began, so that is an excellent start!
BASIC NIPPLE
FLAT NIPPLE

Chapter 11
The First Stage of Lactation (Colostrum)
Here some fun facts for you! The reason your breasts changed size during
pregnancy is because you already have milk in your breasts, ready to go!
Right now you are currently in a phase called lactation called Lactogenesis
Stage I. During this stage, you are making a highly concentrated breast milk
called colostrum. The colostrum is full of anti-oxidants, antibodies, and white
blood cells (to start the process of repairing your baby’s leaky gut). All babies
are born with a leaky gut, like a porous rock, so that these important
components of the milk can pass through the digestive system and get right into
their bloodstream. Your baby is born from a very sterile environment, to very
non-sterile environment, especially if they’re born vaginally. The colostrum
will protect your baby from our bacteria filled world, like giving them a big
antibiotic shot.
The bumps on your areolas have also grown in size, and your areolas are now
bigger and darker. Your baby will only be able to see contrast, so that is why
you now have a bull’s-eye on your chest. Don’t worry; they won’t be like this
forever. The bumps on your areolas are called Montgomery Glands. The
almost undetectable fluid that is secreted serves as a lubricant, and smells like
the amniotic fluid. So yes, your mom is right. Your baby can smell you and
knows that you are there. They use their sense of smell to guide them to the
breast.
Newborns do not get a lot of volume in the 1st few days, and they are born
with their intestines full of this black tar looking poop called Meconium.
Because babies poop out this Meconium, even when they are only eating about
1 teaspoon per meal, all breastfed babies lose weight in the first 3-4 days.
During the colostrum phase babies just do a lot of sucking. They typically do
10-12 bursts of sucking in a row... suck, suck, suck, suck, suck, suck, suck,
suck, suck, suck, suck, pause... suck, suck, suck, suck, suck, suck, suck, suck,
suck, suck, suck, pause.. I’m getting really sleepy mommy... and I am asleep.
This is very common, because the baby is using a ton of effort for not a lot of
return. A baby needs calories for strength and endurance, so we like to keep
the baby alert and feeding by “politely” annoying them. This little trick is

called the milk pump.
This handy “annoying aid” will wake that baby just enough that they will keep
eating, and it will not stimulate any of the reflexes that can interrupt the feeding
(for example: touching a babies cheek may cause the baby to pull off of the
breast because of the reflex). Another great way to keep a baby awake is to
increase the volume. How do you do that? Simply grab and squeeze the boob
like a lemon. Not a massage, but literally grabbing a hold of a section of the
breast and squeezing. Your breast is filled with tons of little sacks of milk, so
you can’t grab a wrong spot!

Chapter 12
The Pamela Anderson Phase!
The Second Stage of Lactation
A huge hormonal shift will happen after the delivery of the placenta, and your
milk will increase in volume around day 3. This is commonly referred to as the
milk “coming in”.
When you deliver your baby, your prolactin levels remain high, while the
delivery of the placenta results in a sudden drop in progesterone, estrogen, and
HPL levels. This abrupt withdrawal of progesterone, in the presence of high
prolactin levels, stimulates increased milk production (the second stage of
lactation). This hormonal shift is what also causes us to develop Postpartum
Depression and Postpartum Anxiety.
The milk supply increasing in volume typically happens in humans around day
3, but it can be delayed for several days due to 3rd Spacing. During this stage,
the more that milk is removed from the breasts, the more the breast will
produce milk.
Why wouldn’t your milk “come in” or increase in volume around day 3?
Water!!! If you have an epidural or a C-Section, they need to give you IV fluids
to keep your blood pressure low, to prevent you from having a heart attack. A
heart attack is the last thing we need, so we just need to look for signs that we
need to flush some of that water out of the system. About 14 hours after
delivery, look at your feet. If they are swollen, place two fingers on your feet
to see if the fluid moves and creates an indentation. If it does, that is the fluid
moving and you have 3rd Spacing. This fluid is not only in your feet, it is also
in anything that hangs: Your butt, nose, hands and breasts. We need to get as
much of this fluid out of your body as soon as possible, or your milk will not
increase in volume and your baby will start loosing too much weight. If you
see this swelling in your feet about 14 hours after delivery, you need to drink A
TON of water. Tap water, Vitamin Water, a cut up watermelon, whatever! The
only way you will get rid of this extra fluid is by peeing it out, and the only
way to pee is by drinking.
3rd spacing is a very common cause of supplementation in the first 2 weeks,

and could severely impact your success at breastfeeding. Here is a photo of a
mom that labored with IV fluids for 14 hours:

Chapter 13
Infant States Proven By Research
Why are you so darn tired! Because your baby has a different sleep cycle than
you do, and you are waking up and functioning when you would normally be in
deep sleep. The amazing team at UC Davis has taken data, dating all the way
back to the 1800’s, and has shared this information with us. Remember, what
you read below is not theory, or someone with a great idea on how to listen to
your babies cries, this is evidence-based fact.
Babies have several different states. They can move through states very
quickly, making it hard for parents to know why their baby is behaving the way
she is. Being aware of cues and paying attention to the baby’s surroundings can
help you understand why the baby might be upset or overly sleepy.
Here are a few things the research has shown us:
• Infants “cycle over and over” through active sleep, quiet sleep, and waking
• Active sleep (REM) is considered to be important for brain development
• Babies dream and blood flows to the brain bringing nutrients to active
brain cells
• Your baby will cycle through quiet sleep, a deep sleep with no dreaming
or movement. It is important for the baby’s brain to rest, and this will be
your only true break during the day. Use them wisely!
Although all healthy babies are different, most move through the states in
similar ways. If babies are very sleepy or very upset, it may take some time for
them to respond. If a baby does not respond at all to the suggestions below
(after several minutes), please see your doctor.
Infant States - Birth to 6 months
DROWSY
• Variable movement

• Irregular breathing
• Opens and closes eyes
• Tired eyes
• Delayed reaction time
LIGHT SLEEP (Active Sleep)
A lot of your baby’s brain development happens AFTER they are born, and
that requires them to dream a lot. Infants are on a 60 minute sleep cycle, and
the first 20 - 30 minutes of sleep they will be in light sleep (dreaming). If you
put them down in this state, they are very likely to wake up. Husband and
grandma job! Hold the baby for 20 - 30 minutes after you breastfeed, until they
transition to deep sleep.
• Some movement
• Irregular breathing
• Facial movement
• Rapid eye movement (REM)
• Easily awakened and startled
DEEP SLEEP (quiet sleep)
In this sleep state, the infant will be very relaxed and have no muscle tension.
This is when you can put the baby down and they will stay asleep.
• No body movement
• Regular breathing
• Bursts of sucking
• Not easily awakened

CRYING
• Tears
• Jerky movements
• Color changes
• Muscle tension
• Rapid breathing
• Generally doesn’t respond quickly
IRRATABLE
• Lots of movement
• Irregular breathing
• Eyes open, but not focused
• Sometimes fussy
• Sensitive to body and surroundings
• Common before feeding
QUIET ALERT
• Little body movement
• Eyes wide open
• Steady, regular breathing
• Very responsive
• Wants to play and interact

• Requires energy and can make babies tired
Waking an Infant:
Sometimes babies are very sleepy and may be hard to wake for feeds.
Newborns of mothers who had medication during labor may be particularly
sleepy. Fortunately, baby’s brains are made to react to varied stimulation.
When a sleepy baby needs to wake up, it is best to use different touches,
sounds, and positions to stimulate the baby’s brain.
Examples:
• Change the baby’s position
• Remove the baby’s clothes and/or change her diaper
• Touch the baby gently in several different places (toes, hands, tummy)
• Call the baby by name several times
Repetition to Soothe:
Whenever a baby is crying, caregivers should be encouraged to try to identify
why the baby is crying. Once the baby’s needs are met, he may still be fussy.
Fussy babies will calm down when caregivers remain calm and use soothing
sounds and motions over and over again. Remember, it may take a few minutes
or more to calm a baby who is very upset.
Examples (repeat over and over):
• Sing a song softly
• Hold the baby close and rock gently back and forth
• Rub the baby’s back
• Say the baby’s name in a calm voice

One of the most astonishing things about newborns is their ability to
communicate almost from the moment they are born. Without words, they
manage to let their parents know when they want to eat, learn, play, or rest.
They also can use their bodies and some awful noises to send unmistakable
signals when they need a break (or a diaper change!). In the past, experienced
friends and family members were there to help moms “decode” baby
messages. These days, many new parents are on their own in trying to
understand their babies’ signals, called “cues.” In this post, we’ll help you
translate the seemingly random movements and sounds that your baby makes
into comprehensible messages. We’re going to tell you about “engagement
cues,” “disengagement cues,” and “clustered cues.”
Engagement cues – When babies want to interact with the people who love
them (or anyone nearby), they will instinctively look, move, and make noise in
specific ways. Collectively, these movements and noises are called
“engagement cues.”
What you’ll see – Your baby will have wide-open eyes and look at you or a
toy as if they are trying to memorize what they see. Their faces and their bodies
will be relaxed and they will use smooth body movements. Older babies may
smile and try to touch or taste whatever interests them. When they are very
excited, babies will kick their legs and squirm with glee.
What you can do – Using engagement cues, your baby is asking you to help her
learn more about you and her new world. At first, your baby will be content
just looking at your face and listening to your voice. Later, she’ll want to play
more complicated games. Enjoy this time together but be prepared to watch for
signs that your baby might be tiring. Engaging with you is hard work!
Disengagement cues – When babies need a break, either for a moment or a nap,
they’ll use a different set of movements and noises to make sure you know it.
These signs are called “disengagement cues.”
What you’ll see – Your baby may close his eyes, turn his face or body away
from you or he may arch or twist his body away. His muscles will be tense and
he may frown or look like he is about to cry. If he’s not allowed to take a
break, he will start crying to make sure you know what to do. Older babies
will stiffen their hands and bring them up towards their faces; they may try to

change position, have you pick them up or put them down.
What you can do – Let your baby take a break! Stop whatever you were doing;
reduce stimulation in the environment (noises, lights, toys, or interactions) that
might have been too much for your baby. Pay close attention and see if your
baby is happy with a short break or if he may need a longer one or a big change
of scene. Babies who are over stimulated by what is going on around them will
use disengagement cues but babies have a very limited ability to communicate.
While they can tell you when they need a break, they can’t tell you why they
need the break. If you pick up your fussy baby and he arches away from you, he
might be trying to tell you that the TV is too loud or that the dog smells bad.
Sometimes the problem will be obvious; other times you’ll need to be a
detective to figure out what has upset your baby.
The Ultimate Baby Body Language: Clustered Cues
It wouldn’t make sense that it could be hard to tell when a baby is hungry. If
people needed a PhD to tell when babies needed to eat, babies wouldn’t
survive. Babies will give parents lots of cues, called “clustered cues,” when
they need them to do important things. A hungry newborn will move her head
looking for something to suck on. She will pull her hands and her knees
upward toward her face. She will make sucking noises and try to suck on
anything she can find. If no one feeds her right away (babies don’t like to
wait), she will start crying while still using all the other cues. Older babies
will try to get into a breastfeeding position, or excitedly reach for the bottle or
spoon. Babies use clustered cues to show they are full too. They relax their
muscles; slow down in their eating, let their hands fall away from their face,
and sometimes fall asleep. Making sure you know when to stop feeding is just
as important to your baby as letting you know she needs to eat. It is important
when parents hear their baby’s cry that they check for clustered hunger cues
before they assume they are hungry.
Creating Your Own Special Language
Now that I’ve made it all sound so simple, I do have to warn you that some
babies are not born able to give clear cues. Some babies have to develop their
skills over the first few days and weeks. Fortunately, nature makes sure that
things turn out well; when parents respond to babies’ signals, babies get better

at using cues and parents get better at reading them. After a relatively short
time, parents and babies develop their own special language and this continues
as children get older and learn other ways to communicate, including using
words. We’d love to hear about your baby’s special ways of communicating
with you.
References:
1. UC Davis Human Lactation Center / FitWIC Baby Behavior Study
2. Brazelton, TB (1973) Neonatal Behavioral Assessment Scale. Clinics in Developmental Medicine, No.
50. JP Lippincott, Philadelphia.in collaboration with the UC Davis Human Lactation Center
3. Secrets of Baby Behavior: Blog post Friday, June 26, 2009: Dr. Jane Heinig – Executive Director of the
UC Davis Human Lactation Center and the Editor-in-Chief of the Journal of Human Lactation.

Chapter 14
The Crucial First 2 Weeks
Why are the first 2 weeks so important when it comes to breastfeeding? In the
first 2 weeks a lot is going to happen. Your baby’s going to lose weight, gain
weight, you’ll go from having practically no milk, to having a lot of milk, and
this is when you establish the prolactin receptor sites in your breast.
Just picture if 10 of us have cell phones and there’s only 4 plugs, 6 of those
cell phones were going to die. That’s exactly what happens with prolactin
receptor sites; if they don’t get set up in the 1st 2 weeks they die. Your brain
controls how much milk you make, so for moms that do not put the baby on the
breasts in the 1st 2 weeks, and do lots of formula supplementation without
pumping, have a real hard time down the line boosting their milk supply.
If you can give me (and your baby) 2 weeks of your life to: establish your milk
supply, get through the hardest stage, regain your baby’s birth weight, and push
through any issues, you have a very good chance to be successful at
breastfeeding for as long as you want to.

Chapter 15
Establishing A Milk Supply
Remember, the first 2 weeks of BF are the most important in establishing your
milk supply, and insufficient milk removal is number one cause of low milk
production. Here are a few rules to live by if you want to have a great milk
supply:
Rule #1: Empty Out That Milk 8 Times a Day!
Breastfeeding is demand and supply, so you have to get the milk out, in order
to make more milk. If there are ANY problems in the beginning, including latch
issues or engorgement, you should add in some pumping sessions so that a
good supply can be established. Simply pump directly after a breastfeeding
session.
Rule #2: You will need to breastfeed or pump a minimum of 8
times every 24 hours for the first 6 months.
Typically a breastfed baby eats about 10 times a day, but 8 is the absolute
minimum. I know this sounds overwhelming, but your baby will become very
efficient at the breast and you will be breastfeeding about 30 – 45 minutes
every 24 hours when your baby is 3 months old. A lot of babies will sleep long
periods, but you will need to fit in those 8 pumping or breastfeeding sessions if
you want your baby to thrive.
Rule #3: Prolactin Regulates Your Milk Supply. If you have any of
the listed precursors for low milk supply, you will want to consider boosting
your prolactin before your prolactin goes back down to pre-pregnancy levels
at 2 to 3 weeks postpartum.
A lot of people will NOT tell you these breastfeeding rules because they are
afraid you will get scared and not even try. I find if I tell my patients the truth,
they are better prepared. Don’t worry, you won’t be breastfeeding 8 hours a
day for the first 6 months, each day your baby get’s bigger and stronger they
also get more efficient. A 3-month-old baby could drink 5oz of breastmilk from
the boob in 5 minutes. Trust me, I see it everyday.

Milk production is a constant, ongoing process. Every time the nursing baby
consumes milk, the mother’s body automatically makes more milk to replace it.
The more often the baby feeds, the more milk the mother’s body produces. If
the baby does not take the milk directly, it must be regularly removed by hand
or with an efficient breast pump about as often as the baby usually feeds. This
process is called expressing milk. If a baby does not breastfeed and the mother
does not express milk, the mother’s breasts become overly full and
uncomfortable. This can lead to an infection and potentially a drop in her milk
supply.

Chapter 16
The Breastfeeding Hormones - Oxytocin and Prolactin
A huge hormonal shift happens after the delivery of a baby, and this shift leads
to “increased milk volume” commonly referred to as the “milk coming in”. At
birth, prolactin levels remain high, while the delivery of the placenta results in
a sudden drop in progesterone, estrogen, and HPL levels. This abrupt
withdrawal of hormones moves you to the second stage of lactation,
Lactogenesis Stage II. This typically happens in humans around day 3, but can
be delayed for several days due to 3rd Spacing. During this stage, the more that
milk is removed from the breasts, the more the breast will produce milk.
While the baby is breastfeeding, the mother’s body releases two important
hormones: Oxytocin and Prolactin.

Oxytocin has important effects on both the breasts, and the uterus. In the
breasts, Oxytocin is the hormone that squeezes the little sacks of milk (your
“let down”), and causes the milk to come out of the nipple. Fun fact! Only 50%
of women feel a “let down” so if you don’t feel it, don’t stress about it.
Oxytocin is also responsible for causing the uterus to contract and get it back to

its normal size. So, you may feel contractions when you first start nursing, but
it’s a good thing.
Prolactin is the hormone that stimulates milk production (it’s true, your brain
controls how much milk you make!). It is produced by the pituitary gland in the
brain, and is ONLY released when a baby compresses the areola and peaks
when the mom is in REM sleep. Not when pumping. Prolactin levels “decline
over the course of lactation but remain elevated for as long as the mother
breastfeeds, even if she breastfeeds for years.” It also suppresses ovulation, so
you won’t get a menstrual cycle, yay!
Prolactin levels rise and fall during and after pregnancy, then about 2-3 weeks
postpartum, the milk supply works off of prolactin surges when the baby
breastfeeds and when mom is in REM sleep. REM sleep with a new baby,
that’s a laugh.
Prolactin surge postpartum – HUMAN
Prolactin surge postpartum – COW

LOOK FAMILIAR :)
“For any hormone to exert its biologic effects, however, specific receptors for
the hormone must be present in the target tissue.” What that means is that
frequent feeding in the early days increases the number of prolactin receptor
sites within the breast. Studies show that a woman’s milk supply is dependent
on the number of prolactin receptors established in the breast in the first two
weeks.
Oxytocin promotes a desire to touch and be touched. Nursing a baby produces
Oxytocin in both mother and child, and this is a major part of what initially
bonds the mother and her baby. Oxytocin’s main role in breastfeeding is that it
stimulates the milk ejection reflex. Oxytocin lowers your blood pressure and
cortisol levels, it reduces pain, makes you thirsty, and it can make you sweat
(so keep that antiperspirant handy). A recent study showed that Oxytocin
lowered pain threshold by 56.5%. So after your baby has any type of
procedure, like a vaccination, breastfeed them immediately after to help with
the pain!

Look at the graphs above to see how the prolactin levels decrease after
delivery of the placenta. This is why it is so important to breastfeed the first 2
weeks, and if you have to supplement, to do it on the breast. Really try not to
feed with a bottle for the first 2 weeks, or supplement with a syringe and your
finger. You would want to supplement on the breast.
References:
1. Prolactin: Physiologic and Pathologic Associations / C. Matthew Peterson, Department of
OB/GYN U of U College of Medicine Battin et al., 1985; Cox, Owens, & Hartmann, 1996
Extremely low doses of oxytocin reduce pain sensitivity in men
Yu. V. Uryvaev, G. A. Petrov
Translated from Byulleten’ Eksperimental’noi Biologii i Meditsiny, Vol. 122, No. 11, pp. 487-489,
November, 1996
2. Level Of Oxytocin In Pregnant Women Predicts Mother-Child Bond Publised in Science Daily Oct. 16,
2007
3. American Academy of Family Physicians. (updated 2003). Breast feeding: Hints to help you get off to a
good start.
4. American Academy of Pediatrics. (updated 2004). A woman’s guide to breastfeeding. Briefel, R.R.,
Reidy, K., Karwe, V.

Chapter 16
Positioning and Latch – The Fundamentals
of Breastfeeding Comfortably
There are 4 basic positions in breastfeeding, and positioning a baby properly
is extremely important for both mom and baby. Positioning facilitates latch on,
and if a baby isn’t positioned properly they can’t latch on properly. If you ever
met anyone that told you how much breastfeeding hurt, and they had painful
bleeding nipples, they were doing something wrong. It IS normal to experience
about 30 seconds of toe curdling pain when a baby first latches on, but the pain
should go away in a few days. The nipple is a ligament and we will talk a little
more about that in this chapter.
Here are the basic breastfeeding holds:
• Football Hold
• Cradle Hold
• Side Lying (Nursing lying down)
FOOTBALL HOLD

CRADLE HOLD

Infant Reflexes and Their Effect on Positioning and Latch
Infants are born with reflexes specifically designed for breastfeeding! There is
an amazing video that a show in my prenatal breastfeeding class of a baby
latching on the breast with absolutely no assistance whatsoever. How the heck
does the baby do that? The baby uses their sense of smell to guide them, and
they are born with reflexes, all designed to teach a mom what to do.
Reflex #1: If you touch the back of the baby’s head, it is a reflex for them to
pull back. As you can see in the photos we are supporting the baby by the back
of the neck to avoid this reflex. Your baby has no head control yet, so they are
a lot less frustrated when you help them get on the breast quickly. The patience
of an infant is even less than your husbands, ha ha.
Reflex #2: If you touch a baby’s cheek they turn.
Reflex #3: If you touch a baby’s lips they open their mouth.
Reflex #4: If you hold the baby up and put the bottoms of their feet on the
ground they will step.
Reflex #5: If you lay a baby down on their back their arms will go up and that

is the startle reflex. The startle reflex is the one reflex that we keep; if you
were to fall off of the building you would automatically do the startle reflex.
That is a morbid thought by I just said that so you could have a visual!
Positioning Is More Important Than You Realize
To position the baby properly we have to build up pillow table by either a
stack of pillows or, my absolute favorite, the Breast Friend breastfeeding
pillow. If the baby is not positioned properly with a pillow table, they will not
be able to latch on properly. The mother will also experience pain in her neck,
shoulders and her lower back from leaning towards the baby. We always want
the mom to bring the baby to her, not to lean in towards the baby.
My favorite position for the 1st few days after babies born is the football hold.
It looks much similar to the Heisman Football Trophy because the baby will be
tucked under your arm like a football. The reason I like this hold is because it
allows the mom to see the most of what’s going on. Some new mom’s are so
stressed out that their baby can’t breathe while on the boob, that they actually
break the latch by putting pressure on the boob to create an airway. I promise,
if your baby can’t breathe they will pull off. The football hold really works
nicely because you can see the baby’s nostrils. It is also very difficult to hear a
baby swallow in the first few days because there’s not a lot of volume, so you
can see the baby swallow very easily while in the football hold. It will happen
every 10-12 sucks day 0 to day 3.
Pretend you are about to eat a huge cheeseburger. Notice how you slightly tilt
your head up when you eat it, that’s a natural feeding position. Keeping that in
mind, the most ideal place for a baby to be positioned is tummy to tummy, and
nose to nipple. If your baby is lying on their back, they will have to strain to
turn her head to eat, and that’s not very comfortable. If you place your baby
nose to nipple, the baby will have to slightly fit tilt their head up which will
put the nipple in the perfect position to stimulate the suck reflex.
After the 1st few days when you feel comfortable breastfeeding in the football
hold we are going to move our pillow table from the side to our belly, and feed
in the cross cradle / cradle position. As you can see in the photo, it’s basically
the same positioning for the baby, tummy to tummy, nose to nipple. The baby
will just be in front of you, instead of to the side of you. Your baby will get

igger, so you will probably grow out of the football position pretty quickly.
FOOTBALL HOLD
CRADLE HOLD

The side lying position is basically the cross cradle / cradle position, just lying
down. Because you will be breastfeeding every 3 hours around the clock, it is
a position you might want to try. It’s a little more tricky to latch a baby on in
this position, but I rather you do this then fall asleep in a chair sitting up
holding your baby at 3 AM. That is dangerous, so if you catch yourself doing
that it may be worth blowing up an air mattress on the floor and do those

eastfeeding sessions in the side lying position.
Now that we have built our pillow table, it is time to stimulate the baby’s
mouth with the nipple so that they will open their mouth.
Latching a Baby Properly
Now let’s talk about proper latch techniques. Again, I go back to the
cheeseburger. Picture a Carl’s Jr. commercial. The model doesn’t politely
whittle away at the burger, she grabs it and squeezes so she can get the whole
thing in her mouth. That’s exactly what we want to do to the breast. We are
going to compress the breast to align with the baby’s mouth, so the baby can
get the most amount of breast tissue in their mouth as possible. Compressing
the breast allows for the deepest and most effective latch.
COMPRESSING LIKE A TACO FOR THE CRADLE POSITION
COMPRESSING LIKE A SANDWICH FOR THE FOOTBALL HOLD

If the baby does not get the nipple far enough back in their mouth they will
compress the nipple against the hard palate and you will get cracked, sore,
bloody nipples. If the baby is compressing your nipple against their hard
palate, you will feel pain that lasts longer than 30 seconds, and the nipple will
look flat on one side like a lipstick when the baby comes off or if you take the
baby off of the breast.
If your baby does not get enough breast tissue in his mouth, or the nipple
retracts, the baby will smash the nipple against the roof of his mouth. Try this;
put your tongue on the roof of your mouth. What you feel is your hard palate.
Behind that is a bump, and behind THAT is the soft palate. Your nipple needs
to go all the way back to the babies soft palate in order to breastfeed without
pain.
There is no way to prepare your nipple for what it is about to experience,
unless I took a vacuum head off and put it on your nipple. The nipple is a
ligament and it will stretch, but there may be pain in the first 30 seconds. We
also have natural nipple inversions, part of the nipple that has never seen the
light of day. The nipple ligament and the inversions will stretch and the pain in

the beginning will soon be a faint memory. See how I mention the first 30
seconds, if it hurts longer than that there is something wrong, and you will need
to seek help from a Lactation Consultant. With these types of issues, I
commonly recommend the use a nipple shield for a 2-week period.

Chapter 17
Nipple Shields
There is a ton of old, outdated information about nipple shields, and a lot of
healthcare professionals that do not agree with their use. If we go back to the
anatomy and physiology of breastfeeding, you would agree that keeping a baby
on the breast is the most important thing. You do not get a surge of prolactin
when you pump, only when the baby is on the breast, and babies get used to the
bottle flow very quickly. Why then are moms using a shield given such a hard
time? It is a complete mystery to me.
Nipple shields have been around since the 1800’s, and used to be made of
metal, wood, or ivory. These types of shields would not provide enough
stimulation, but the newest technology does. The ultra thin piece of silicone
will not harm the milk supply, will increase prolactin, and will lead to less
nipple pain and more efficient milk removal. My favorite brand of shields is
Medela Contact Nipple Shields, and they come in 3 different sizes: 16mm,
20mm, and 24mm. FYI, I use a 20mm nipple shield in 95% of my patients, for
an average of 1-2 weeks, and I don’t use any other brand than Medela.
Each size is based on the size of you nipple, but you may have to go to a
smaller size if your baby will not open their mouth wide enough to go flush up
against the areola. If you see any part of the shield tip, you can try a smaller
sized shield.
Nipple shields can be used for latch issues caused by flat or inverted nipples,
as well as a baby with an oral anatomy issue (tight frenulum) or forceful milk
ejection reflex (baby pulls off gagging and coughing).

NIPPLE SHEILD – CORRECT USE (YOU DO NOT SEE NIPPLE AND
BABY IS COMPRESSING AREOLA

INCORRECT USE OF NIPPLE SHEILD, BABY IS NOT COMPRESSING
AREOLA

Chapter 18
Tounge Tie
Oh look honey; our baby has a heart shaped tongue!
As you can see in this photo, this baby has Ankyloglossia (also known as
tongue tie). The piece of skin that connects his tongue to the floor of his mouth
is short, restricting the movement of his tongue. Tight frenulum’s are common,
they cause major breastfeeding problems, are easily corrected with a quick
snip.
During breastfeeding, the tongue extends over the gum line and protects the
breast against the bony jaw below. If movement of the tongue is restricted, the
baby won’t be able to form a tight seal, create positive pressure, and maintain
a proper latch. Without a proper latch, the baby can’t remove milk from the
breast, and breastfeeding will be painful for mom. It’s estimated that tongue-tie
occurs in 1 in 250 babies.

A frenotomy (cutting of the frenulum) has been a dispute between lactation
consultants and doctors for years, but has regained its place as a standard
medical procedure. In a study conducted in 2010, two infants with
breastfeeding problems caused by ankyloglossia both underwent frenotomy
with good result. The first baby did not effectively extract milk from the breast
drink and did not gain any weight. The mother of the second patient
experienced a great deal of pain and had cracked nipples, caused by an
abnormal suckling action. Recent ultrasound studies reveal that frenotomy
immediately normalizes the suckling action in babies with a tongue-tie, and
randomized controlled trials show that 95% of breastfeeding problems
disappear. There is sufficient evidence to state that frenotomy is a very safe
and useful procedure.
Surgical scissors can cut the frenulum, or the preferred choice is a laser lingual
frenotomy. These lasers are harder to find, but a lot less invasive and there is
less bleeding.
References:
Problematic breastfeeding due to a short frenulum
Author Post ED, Rupert AW, Schulpen 2010
Newborn Tongue-tie: Prevalence and Effect on Breastfeeding
Lori A. Ricke, MD, Nancy J. Baker, MD, Diane J. Madlon-Kay, MD, MS,
and Terese A. DeFor, MS

Chapter 19
How To Supplement on the Breast
As I mentioned in a previous chapter, prolactin is ONLY released when a baby
compresses the areola. This is why it is so important to breastfeed the first 2
weeks, and if you have to supplement, to do it on the breast. Really try not to
feed with a bottle for the first 2 weeks, or supplement with a syringe and your
finger. You would want to supplement on the breast.
To supplement on the breast you would want to supplement with a
Supplemental Nursing System, or a curved tipped syringe that can fit on the
side of the baby’s mouth like this one, on the breast.
Curved Tipped Syringe
A curved tipped syringe is an excellent way to supplement the first few days.
The syringe will hold 10 cc’s of colostrum or formula, and can be fed to the
infant while breastfeeding (either by mom or a helper).
Starter SNS

A starter SNS is $25, but only for 24 hours of use. The tube is very small, and
should only be used if mom has a delay in her milk “coming in”, not intended
for long-term use.
Long Term SNS

The long term SNS is $66 and much easier to use, has a tube for each breast,
does not leak as often, and has less parts to deal with.
The biggest challenge when using an SNS is just getting the tube in the baby’s
mouth. You can tape the tube to the nipple, or run the tube under a nipple
shield. If the tube is not positioned properly, the milk will not drain from the
SNS bottle and you will not see any bubbles. If that is the case, make sure the
tube isn’t pinched with the stopper (common mistake that happens all of the
time) or take the baby off and latch them again.
To clean an SNS, the goal is to get the formula or breastmilk out of the tube
after every feed. After rinsing the parts with water, run water through the tube
after every feed by putting it back together with water in it, and squeezing the
bottle or bulb to force water through the tube.

Chapter 20
Jaundice
Jaundice in newborns produces a yellow color to the skin and eyes, is caused
by a buildup of bilirubin in the blood. In the womb, a fetus eliminates byproducts,
such as bilirubin through the umbilical cord. After birth, the baby’s
organs take over these jobs. Newborns may develop jaundice from a buildup
of bilirubin for slightly different reasons.
Why should you know about Jaundice? Because it makes a baby sleepy and
that can impact breastfeeding. If you have a baby that has lost weight, is
working hard on the breast, and they are Jaundice, you are going to have to
stimulate this baby before and during breastfeeding to keep them awake. You
may even have to pump and do a few bottles a day, simply due to the fact that it
is a lot less effort for the baby. Don’t worry about the baby getting used to the
bottle at this point, we need to do what is best for the baby and flush out this
buildup of bilirubin.
TYPES OF JAUNDICE
Physiologic Jaundice
Physiologic jaundice develops between 1 and 5 days after birth because
babies’ organs are not yet able to get rid of excess bilirubin effectively.
Whether jaundice is noticeable depends in part on how high blood bilirubin
levels reach.
If noticeable, the yellowing of the skin and eyes usually appears about 24 hours
after birth and increases until about the third or fourth day. Most often,
bilirubin levels in the blood then gradually lower and the yellowing fades or
disappears in about a week without causing problems.
Premature babies, whose organs are not fully developed, are less able to
eliminate bilirubin effectively and are more likely than full-term babies to
develop noticeable yellowing related to jaundice.
Breastfeeding Jaundice (or as we like to call it “too many visitors” jaundice.

Breastfeeding jaundice is caused by mild dehydration. Dehydration contributes
to jaundice because it makes removing bilirubin from the body even harder for
babies’ immature systems. Breastfeeding jaundice can occur when a baby does
not get enough fluids, most often because feedings are spaced too far apart or
the milk supply has been delayed. Breast-fed babies who are fed every 4 or
more hours (as are many formula-fed babies) will gradually become
dehydrated, and bilirubin levels in the blood will rise or remain elevated.
Treatment plans of infants with jaundice
Your baby may be placed under lights to bend the bilirubin so it can come out
via the urine, you may have to supplement with formula (it contains a different
protein that the bilirubin binds to and will be a temporary fix if the supply is
low) or it may be as simple as feeding more often (10 - 12 times a day instead
of 8). Depending on the mom’s milk supply, she may be able to pump and
supplement with her own breastmilk, it all depends on the bilirubin levels and
the recommendation from the pediatrician. Jaundice does make an infant very
sleepy, so sometimes we develop a 48 hour plan feeding 2 or 3 bottles of
breastmilk a day with Breastfeeding Jaundice, so that we can insure the baby is
gaining wait and pooping frequently.
FYI: Supplementing with water or sugar water does not help lower the
bilirubin levels in these babies; it can actually increase the levels and delay
the sealing of the gut and is not recommended.
Usually, breast milk jaundice gradually decreases, although most babies often
have mild jaundice throughout the duration of breastfeeding. Bilirubin levels
rarely rise to harmful levels, and most often health professionals recommend
continuing with exclusive breastfeeding. Sometimes a bilirubin blood test is
done to assure that the bilirubin level is in an acceptable range.
Most of the time bilirubin does not cause problems, but occasionally the
amount of bilirubin in a newborn’s blood rises to a level that could be harmful.
When this happens, the yellowing of a baby’s skin and eyes (jaundice)
becomes more pronounced and he or she may become irritable and sluggish
and have a high-pitched cry. Parents should report these symptoms to their
health professional right away.

Rarely, excessive amounts of bilirubin build up in the blood and lead to
Kernicterus, which can result in brain damage, hearing loss, intellectual
disability, and behavior problems.
References:
American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the newborn infant 35 or
more weeks of gestation. Pediatrics, 114(1): 297-316.

Chapter 21
How Often Should I Be Breastfeeding
You will need to breastfeed your baby 8 or more times in 24 hours (in a
perfect world that is every 3 hours each 24 hour period).
Do you have to wake your baby every 3 hours around the clock?
The answer is yes, until your baby regains their birth weight.
Babies are happy to starve, and if they loose too much weight, they will not
have the strength or endurance to tell you they are hungry.
After a baby regains their birth weight, try to feed every 2 1/2 hours in the
daytime. Babies are born wanting to sleep all day and party all night, so the
more calories you pack in them during the day, you may get a 4 hour stretch of
sleep at night. Infants “cluster feed” or “load” calories by having several
breastfeeding sessions within a short time. This is most likely to happen
between the hours of noon to midnight, when you are making the least amount
of milk.
Although you only need one breast to breastfeed, nipple stimulation is crucial
in the first 2 weeks. From day 1 to day 3, feed the baby on one side for 15
minutes, and then switch to the other side. Once your milk “comes in” or
increases in volume somewhere between day 3 and day 5, feed the baby on one
side and when they self detach, or they are no longer actively sucking when
you stimulate them, remove them from the breast, burp them, then offer the
other side. It’s a good idea to get used to always offering the other side, even if
they don’t want it. Just think of it like dinner and dessert. You always offer
desert, but if they don’t want it, it’s ok.

Chapter 22
Why Do I Have A Fussy Baby
Very simply, babies fuss for the same reasons adults fuss: they hurt either
physically or emotionally, or they need something. They may need a break or
something different, they may be tired, too hot, want to be held, or just hungry.
There are lots of other reasons babies cry, but we are going to talk about a
baby that is not soothed even when you respond to their cues.
The term colic is used as a “catch-all” term for babies who cry a lot every day.
Experts call excessive infant crying “persistent” or “unexplained” crying rather
than colic. Typical newborns cry a little more than 2 hours per day, fussing
frequently in relatively short spurts. Babies with colic cry more than 2 to 3
hours per day, for longer periods, and they don’t respond to their parents’
efforts to soothe them.
While there are great soothing technique’s we can learn, the evidence shows us
2 very important things to consider with infants.
#1: All babies are born with a leaky gut. A leaking gut lining is necessary so
that they can fully benefit from the colostrum. At this time a porous gut wall is
critical for the baby’s survival, but can cause a food protein intolerance.
#2: There is a tube inside the throat that connects the mouth to the stomach
called a lower esophageal sphincter (LES). Until a baby is about 6 months old,
they are more likely to have the LES relax when it should remain shut. As food
or milk is digesting, the LES opens and allows the stomach contents to go back
up the esophagus.
Typically an infant gut lining seals when they are about 3 months old, and the
LES muscle is more mature at about 6 months of age. Hmmm, it’s all starting to
make sense! When are you most likely to have unexplained crying? From 3
weeks to 6 months of age. Let’s go into more detail about the two major causes
of fussiness in an infant.

Chapter 23
Food Protein Intolerance and Lactose Intolerance
Colic is a term that is used to describe a type of behavior and/or symptoms of
an infant. Despite 40 years of research, there is not a clear-cut cause. A baby
diagnosed with colic will have uncontrollable, extended crying in a baby who
is otherwise healthy and well fed. Every baby cries, but babies who cry for
more than three hours a day, three to four days a week, may have colic.
When a baby has colic, the life of the family is turned upside down. The
parents find it extremely stressful and upsetting when their baby is crying for
hours and cannot be comforted. For first-time parents in particular, it can be a
shock and a disappointment. Colic symptoms can start within two to four
weeks after birth and the child suffers from it for up to three months.
Symptoms vary from child to child, and can range from lots of gas and stomach
rumbles, all the way to crying 14 hours a day. Doctors don’t know precisely
what triggers the condition and theories include: the overworking of the
intestines, bowel movements may be too slow, eating too fast, eating too much,
or swallowing too much air without burping.
We don’t know exactly why your baby is showing these symptoms, but we can
look at what we DO know about an infant’s anatomy. All babies are born with
a leaky gut! It’s a good and bad thing. A leaky gut is a common term that is
used to describe a condition where the lining of the intestinal tract has become
porous, allowing large food particles entry into the blood stream causing
immunological reactions. Infants receive much more than just nutrients from
mother’s milk. They also receive mother’s antibodies, which are large protein
molecules. In order to allow the flow of these antibody molecules into the
baby’s bloodstream, the intestinal lining has to be leaky enough to
accommodate the large molecules.
The offending food protein enters the infant’s bloodstream, and the immature
immune system treats it like a foreign object or antigen (i.e. virus), and reacts
to it forming a non-IgE antibody.
Symptoms of food intolerance may include:

• Recurrent hives
• Reflux
• Gas
• Stuffy or runny nose
• Leg cramps
• Irritable behavior
• Mucus in stool
The onset of symptoms after eating a problem food can vary from almost
immediate to delayed (up to 24 - 48 hours). Since a food intolerance isn’t an
IgE immunological reaction to food, blood and skin tests are not helpful, as
they may or may not show up on these tests.
Some researchers are now theorizing that untreated food (protein) intolerance
may sensitize the immune system, making the infants more prone to allergies.
This is because the incidence of allergies later in life appears to be higher in
children who had symptoms of protein intolerance as infants. This is still only
a theory and there has been no research done yet into this area that we are
aware of.
Protein foods are among the most common foods that cause sensitivities in
babies. After cows milk, other foods to consider are soy, nuts (especially
peanuts and almonds) red berries, and tomatoes. I know what you’re thinking,
that’s everything I’m eating right now! A food protein intolerance usually
occurs between 2 and 6 weeks of age, although some have reported symptoms
beginning as early as the 1st week. The cow’s milk protein is the offending
antigen in 50 to 65% in cases, and research has proven that food proteins can
pass whole into human milk. Although for most babies exposure to these food
proteins do not cause a problem, for allergic babies, reactions sometimes
occur. Although an elimination diet helps in many cases, it can be difficult, as a
mother may need to severely restrict her diet to get results. As an alternative,
some doctors recommend that mothers stop breastfeeding and feed their babies

hypoallergenic formulas.
Treatment Options
Digestive Enzymes for mom: Studies show that using a digestive enzyme that
help break down fats, proteins, and carbohydrates, successively break down
food more thoroughly in the mother’s digestive system, so that it is less likely
to pass intact into her milk. Prescription Digestive Enzyme: Pancreas MT4, or
the over the counter alternative Milkalicious Pancreatin.
In one study on this treatment at the University of California at Davis, 16
breastfeeding mothers begin in the elimination diet starting with dairy, soy,
nuts, strawberries, and chocolate and started taking the Pancreas MT4 as
directed. In 13 of the babies bloody stools resolved, and colic symptoms
decreased while the mothers continued to breastfeed. Although this treatment
shows promise, more studies are needed with the control group as well as a
treatment group to better evaluate the efficiency of this new option.
Probiotics for baby that help aid in digestion: In a recent study, ninety
breastfed colicky infants were assigned randomly to receive either the
Lactobacillus reuteri probiotic or simethicone (MYLICON) each day for 28
days. The mothers avoided cow’s milk in their diet and monitored daily crying
times. Food protein intolerance symptoms improved in 95% in the probiotic
group and 7% in the simethicone group within 1 week of treatment. Saying
probiotic is kind of like saying Soft Drink. There is Coke, Pepsi, Sprite, etc.
All probiotic strains come from different sources, and all probiotics that start
with Lactobacillus come from breastmilk. These good bacteria survive the
stomach acids and colonize in the gut. The Bio Gia Lactobacillus reuteri liquid
probiotic is the one referenced, and cannot be found in a general probiotic you
buy at the store. Bio Gia lactobacillus reuteri comes in a liquid form and is
available at several retailers including Milkalicious and Walgreens.
Lactase enzyme to treat Lactose Intolerance’s: Recent studies including those
performed in the Department of Pediatrics, Guy’s Hospital, London, published
in the Journal of Human Nutrition and Dietetics and another reported on the
British Journal of Community Nurses, have shown that nearly half the babies
suffered colic due to lactose intolerance. The babies’ symptoms had seized or
significantly reduced upon treating milk with lactase enzyme. Liquid Lactase

enzyme available over the counter at most drug stores: Colief Infant Drops
Lactase enzyme is the most commonly used.
This is a typical care plan I give parents for a baby suffering from colic. This
is of course only after I have confirmed that the mom has an ample milk supply,
and the baby is gaining weight (lack of food will cause colic like symptoms as
well).
Plan of Care:
Diagnosis: Colic
One-Week Treatment Plan
1. In order to see if a food protein intolerance is the cause of your infant’s
crying episodes and gas; I am recommending the L. Ruteri probiotic. You can
put 5 drops of the Bio Gia probiotic on your nipple, a pacifier, or in a bottle,
once per day.
2. For a week, please stop drinking cows milk and yogurt, and switch to rice
milk and rice yogurt (not soy). At this time you do not need to eliminate ALL
dairy, just avoid the obvious. This includes Whey Protein shakes, as Whey is
another term for the cow’s milk protein. In addition, please eliminate
chocolate, nuts, strawberries and tomatoes. You can eat gassy foods, like
broccoli, in addition to spicy foods and garlic. These are not the cause of the
gas of your baby, it is a myth. Only things that go into the bloodstream go into
the milk, and the Cows Milk, Nut, and a protein found in Red items
(strawberries and tomatoes) are the leading cause of gas and fussiness in
infants.
3. Please take 2 Pancreas MT4 or Milkalicious Pancreatin digestive enzymes
with each meal, and 1 with each snack.
4. You can also add 4 drops of Colief® Infant Drops to breastmilk (or
formula) in a bottle, or feed directly to infant prior to each feeding. These are
digestive enzyme drops that help babies better digest the lactose, or milk sugar,
in breast milk or formula.

5. If you do not see symptom relief within 1 week, a full elimination diet is
recommended. You can find a link to a recommended diet at
www.milkalicious.com.
Getting a Diagnosis / How Can You Know For Sure
A doctor may request a fecal occult blood test to look for blood that’s present
due to a food protein intolerance. To test the stool for the presence of blood, a
noninvasive test called the fecal occult blood test (FOBT) is performed. The
test detects hidden (occult) blood in the stool — blood that cannot be seen by
the naked eye. Blood may come from any part of the digestive tract, from the
esophagus to the anal area.
Unlike most other lab tests, parents at home often collect a stool sample, not by
health care professionals at a hospital or clinic. The doctor or hospital
laboratory will usually provide written instructions on how to collect a stool
sample.
References:
1. Lactobacillus reuteri (American Type Culture Collection Strain 55730) Versus Simethicone in the
Treatment of Infantile Colic: A Prospective Randomized Study Resolution of Lactose Intolerance and
Colic in Breastfed Babies
Robyn Noble & Anne Bovey
2. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and
Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of
Complementary Foods, and Hydrolyzed Formulas Pediatrics 2008;121;183 Frank R. Greer, Scott H.
Sicherer and A. Wesley Burks
3. Detection of peanut allergens in breast milk of lactating women. Vadas P, Wai Y, Burks W, Perelman
B JAMA. 2001 Apr 4;285(13):1746-8.
4. Lactose Intolerance, Diarrhea, and Allergy Maryelle Vonlanthen, MD from Breastfeeding Abstracts,
November 1998, Volume 18, Number 2, pp. 11-12. Pediatrics. 1991 Apr;87(4):439-44.
5. Human breast milk contains bovine IgG. Relationship to infant colic? Clyne PS, Kulczycki A Jr
Washington University School of Medicine, St Louis, Missouri. Riordan and Auerbach Sorva 1994 Clyne
and Kulczycki 1991

Chapter 24
Acid Reflux
The lower esophageal sphincter, a muscle located at the bottom of the
esophagus, opens to let food into the stomachand closes to keep food in the
stomach. When this muscle relaxes too often or for too long, acid refluxes back
into the esophagus, causing vomiting or heartburn.
Everyone has gastroesophageal reflux from time to time. If you have ever
burped and had an acid taste in your mouth, you have had reflux. The lower
esophageal sphincter occasionally relaxes at inopportune times, and usually,
all your child will experience is a bad taste in the mouth, or a mild, momentary
feeling of heartburn.
Infants are more likely to experience weakness of the lower esophageal
sphincter (LES), causing it torelax when it should remain shut. As food or milk
is digesting, the LES opens and allows the stomach contents to go back up the
esophagus. Sometimes, the stomach contents go all the way up the esophagus
and the infant or child vomits. Other times, the stomach contents only go part of
the way up the esophagus, causing heartburn, breathing problems, or, possibly,
no symptoms at all.
Some infants and children who have Acid Reflux / Gastroesophageal Reflux
Disease (GERD) may not vomit, but may still have stomach contents move up
the esophagus and spill over into the windpipe (the trachea), which can cause
asthma and/or pneumonia.
Infants and children with GERD who vomit frequently may not gain weight and
grow normally. Inflammation (esophagitis) or ulcers (sores) can form in the
esophagus due to contact with stomach acid. These can be painful and also may
bleed, leading to anemia (too few red blood cells in the bloodstream).
Esophageal narrowing (stricture) and Barrett’s esophagus (abnormal cells in
the esophageal lining) are long-term complications from inflammation that are
seen in adults.
What are the symptoms of GERD?

Heartburn, also called acid indigestion, is the most common symptom of
GERD. Heartburn is described as a burning chest pain that begins behind the
breastbone and moves upward to the neck and throat. It can last as long as two
hours and is often worse after eating. Lying down or bending over after a meal
can also contribute to heartburn. Most children younger than 12 years of age
who are diagnosed with GERD will experience a dry cough, asthma symptoms,
or trouble swallowing, instead of classic heartburn.
The following are other common symptoms of GERD. However, each child
may experience symptoms differently. Symptoms may include:
• Belching
• Refusal to eat
• Stomachache
• Fussiness around mealtimes
• Frequent vomiting
• Hiccups
• Gagging
• Choking
• Frequent cough
• Coughing fits at night
• Wheezing
• Frequent upper respiratory infections (colds)
• Frequent ear infections
• Rattling in the chest

• Frequent sore throat in the morning
• Sour taste in the mouth
The symptoms of GERD may resemble other conditions or medical problems.
Consult your child’s doctor for a diagnosis.
Truthfully, the tests to determine if an infant has acid reflux are so invasive; it
is extremely rare that these tests will be ordered. Treatment is designed based
on process of elimination, because your doctor does want your baby to feel
better.
Treatment Options
Stick With Breastfeeding:
Breastmilk is best, when it comes to acid reflux! Breastfed babies have been
shown to have fewer and less severe reflux episodes than formula fed babies.
Human milk is more easily digested than formula and is emptied from the
stomach twice as quickly. This is important since any delay in stomach
emptying can aggravate reflux. The less time the milk spends in the stomach,
the fewer opportunities for it to back up into the esophagus. Human milk may
also be less irritating to the esophagus than artificial formulas.
Medications:
Prescription medicines reduce stomach acid, thereby suppressing the
symptoms of esophageal inflammation and pain associated with reflux.
Commonly used medications include Zantac (a brand of the H 2
blocker -
ranitidine) or Prevacid (a brand of the proton pump inhibitor - lansoprazole).
Lifestyle Changes:
• Check with your infant’s doctor first, but elevating the head of the crib or
bassinet
• After feedings, hold your infant in an upright position for 30 minutes

• If bottle-feeding, keep the nipple filled with milk so your infant does not
swallow too much air while eating. Try different nipples to find one that
allows your baby’s mouth to make a good seal with the nipple during
feeding.
References:
Johns Hopkins ABX Guide 2012 (Johns Hopkins Medicine) John G. Bartlett, Paul G. Auwaerter, Paul A.
Pham

Chapter 25
Burping
Truthfully, breastfed babies do not swallow a lot of air because they are on the
breast with an airtight vacuum suction. A lot on mom’s think they are hearing
their baby swallowing air when they are gulping on the breast. It is actually
milk, not air. Then why would you need to burp?
If your baby cries before going on the breast they are swallowing air and will
most likely have a burp. Air bubbles may cause fussiness, and may increase
frequency/risk of spitting up, the infant may act “Fussy” after feeding, and
burping works really well as a wake up technique. It’s OK if there are no
burps! If it is 2am and your baby falls asleep, don’t worry. You can burp him
the next feed and you can get some rest!
How do you burp?

Upright- over shoulder or on chest
Sitting (Mostly used by nurses so that they don’t get spit up on)

Chapter 26
Pulling Off of the Breast / Biting
Luckily, this one is very simple. A baby pulls off the breast for one of two
reasons:
1. Too much milk
2. Not enough milk
If your baby is less than 2 weeks old, it is most likely due to too much milk
(refer to oversupply section). If your baby is older than 2 weeks old, it is most
likely due to a reduction in the supply (refer to increasing milk supply section).
If your baby is biting, it is most likely do to them trying to get more milk out of
the boob and the teeth are getting in the way. In order to get more milk from the
boob, a baby typically pulls back with the nipple in their mouth. If you increase
your supply, this should stop. Your baby loves you very much and does not
want to hurt you, so do not get mad at your baby. They are not doing it on
purpose.

Chapter 27
Engorgement
Your breasts may ache at times when they become uncomfortably full, or
engorged. Most mothers have experienced such fullness in their breasts at one
time or another as their bodies readjust to a baby’s changing demands for
breast milk. A little fullness during the first few days after birth is normal, but
excessive engorgement, which can occur from missed feedings or a change in
how often your baby nurses, can be quite painful.
Feeding frequently on demand helps prevent engorgement, but if your baby is
nursing as often as she wants and is gaining weight, you may have to take extra
measures to relieve the pressure on your breasts. You can, for example, soak a
cloth in warm water and put it on your breasts or take a warm shower before
feeding your baby. It may also help to express a small amount of milk before
breastfeeding, either manually or with a breast pump. For severe engorgement,
you can take ibuprofen, use a cool compress, gel pack, or ice pack between
feedings to relieve discomfort and reduce swelling.

Chapter 28
Increasing Milk Supply
The pump companies do a great job at telling us that we need to get the milk
out in order to make more milk. That is absolutely 100% true. Breast milk
contains a small way protein that slows milk synthesis when the breast is full.
Milk production slows when the breast is full and increases when the breast is
empty. The protein is called FIL. You are now in the established lactation
phase, so milk removal is the primary mechanism for your supply.
Causes of Low Milk Supply
Breast Surgery
• Nerve damage and/or ductal damage
• The longer the amount of time since the surgery, the better
• Breast Reductions tend to create the most difficulty
Insufficient Milk Removal
• #1 cause for low milk supply
Spinal cord injuries
• Nerve damage can lead to insufficient milk ejection
Insufficient Mammary Tissue
• Effects about 1.5% of new mothers
• Hormonal Imbalances
• Retained placenta, thyroid, diabetes, PCOS, obesity, & gestational
diabetes
Accidental Inhibitors

• Allergy medications, nicotine, Welbutrin or Zyban, birth control pills
(even mini-pill), topical estrogen creams
Increasing Milk Supply, what do you need to know!
Insufficient milk removal could be of no fault to the mother. It can be caused by
separation at birth due to the health of the baby, a poor latch, interruption of
breastfeeding out of mothers control, for example, emergency surgery to
remove gallbladder after birth. It is more common to have it happen due to lack
of education on how breastfeeding works and that it is demand and supply.
That would be not feeding frequently enough, or supplementation without the
mother pumping.
Many mysterious low milk production situations are caused by hormonal
imbalances. Common culprits are thyroid, insulin resistance (often tied to
PCOS), and progesterone.
When a mom is trying to boost her supply, there is almost always an overlap in
methods to increase milk: physical and hormonal. For example, if a mom isn’t
making enough milk and needs to supplement with formula, we would have the
mom supplement on the breast with a SNS instead of with a bottle, or have the
mom pump every time she supplemented with formula.
Here are the standard blood labs we recommend for determining the cause of a
reduced milk supply. This is if a hormonal imbalance is suspected if a woman,
that has adequate breast tissue, is not producing 32oz of milk ever 24 hours
with frequent breast empting:
Lactation Hormone Blood Panel
• Fasting Glucose
• Testosterone
• Estrogen
• HCG (to test for retained placenta)
• Prolactin

• Iron
• Thyroid: as of 4/03 some experts suggest TSH range for fertility /
pregnancy .5.3.0 or even .5.2.5 (Mandel, 2005)
How Hormonal Imbalances Effect Breastfeeding
Prolactin is a hormone produced by the pituitary gland in the brain, and you
need it to make milk. A hormonal imbalance can suppress prolactin, and that
will lower the supply. If you have a hormonal imbalance, you could pump 50
times a day, but the supply will only increase slightly, because breastfeeding is
not just physical, it is hormonal.
Prolactin is released upon baby’s stimulation of the areola and peaks during
REM sleep, so you will typically make the most amount of milk between
midnight and noon, and the least amount from noon to midnight.
Tip: If your menstrual cycle returns, your prolactin levels are down
There are foods, herbs, and drugs that boost your prolactin levels:
Foods: Not instant oatmeal, barley, brown rice, beans, sesame, dark green
leafy vegetables, apricots, dates, figs and cooked green papaya. The problem
with using foods to boost prolactin, is that we don’t know if it does! We get all
of our data from dairy cow farmers. Barley to boost supply started a rumor that
beer will increase supply. Problem is, alcohol decreases oxitocin, so the
benefits are outweighed by the negative effect on the milk ejection reflex.
Herbs: Dill, fennel, fenugreek, goat’s rue, and shatavari. We do not have much
data on any of these herbs and the effectiveness, other than the Fenugreek.
Tomas Hale did his own study and put 10 women on fenugeek for one week,
and the milk supply doubled (Tomas Hale’s Book: Medications and Mothers
Milk).
Drugs: Reglan, Domperidone (Motilium), or Metformin (common treatment for
PCOS and Type II Diabetes. (We have data on all 3 drugs via Tomas Hale’s
Book: Medications and Mothers Milk) These are 2 GI drugs for acid reflux

and nausea that are proven to boost prolactin off the charts. The Reglan is the
most common prescription written for low milk supply in the US, but is does
have a potential side effect of severe depression and tardive dyskinesia.
The preferred drug that does not have any side effects like the Reglan (because
it does not cross the blood brain barrier) is called Domperidone. It does not go
into the milk and does not get to the baby, unlike the fenugreek and reglan (does
go into milk).
As I mentioned, prolactin naturally decreases over time, and by elevating the
baseline prolactin levels, it tricks the body into making the most amount of
milk possible. All you have to do is do frequent breast empting (pumping or
breastfeeding) and you will see an increase in your supply. A slight increase is
common in the first 24-48 hours; with up to 2 weeks to see it’s maximum
effect. The goal is to continue to elevate your prolactin levels, and then your
supply will stay consistent.
Below you will find more information on the Fenugreek, Reglan, and
Domperidone (brand name is Motilium). Both boost prolactin. As you can see
in the attached information from Tomas Hale, prolactin levels increased from
12.1 to over 118 with the domperidone, this is what we use if the Fenugreek
does not boost the supply enough. You will know how much the fenugreek
boosts your supply within 1 week. Prolactin is the hormone from the brain that
tells the body to make milk so that is why it triggers the body into making more
milk.
What is PCOS?
• Leading cause of infertility in woman
• Affects 5 - 10% of all women, 50% obese
• Women with PCOS have higher levels of androgen hormones that can
interfere with prolactin reaching its receptors.
• Estrogen is known to inhibit lactation, particularly in the early days after
delivery. Women with PCOS typically have an imbalance called
“estrogen dominance.” If estrogen levels are not down-regulated after

irth, circulating estrogen may interfere with lactation. This is why the
contraceptive pill is not recommended for breastfeeding mothers.
Thyroid Dysfunction
• Types of thyroid dysfunction that effect lactation are Hypothyroidism, and
Postpartum Thyroiditis
• Can begin before, during, or after pregnancy
• Thyroid hormone replacement is first line of treatment for hypothyroidism
- related supply problems.
• High TSH, you’ll have high Prolactin. Low TSH, you’ll have low
prolactin.
Accidental Inhibitors
• Stress and Anxiety
• Sudafed: 65% reduction in supply after one dose
• Hormonal Birth Control Pill (Mini Pill, DepoProvera or Copper IUD best
choices)
• Wellbutrin (Raises Dopamine in the brain)
• Nicotine causes 20% reduction in milk supply
Herbs: Sage, Parsley, and Peppermint (tea, candy, and breath mints like
Altoids)
Fenugreek drug info from Medications and Mothers Milk
Fenugreek is commonly sold as the dried, ripe seed and extracts are used as an
artificial flavor for maple syrup.[1] The seeds contain from 0.1 to 0.9%
diosgenin.[2] Several coumarin compounds have been noted in the seed as
well as a number of alkaloids such as trigonelline, gentianin, and carpaine. The
seeds also contain approximately 8% of a foul-smelling oil. Fenugreek has

een noted to reduce plasma cholesterol in animals when 50% of their diet
contained fenugreek seeds. The high fiber content may have accounted for this
change although it may be due to the steroid saponins. A hypoglycemic effect
has also been noted. When added to the diet of diabetic dogs, a decrease in
insulin dose and hyperglycemia was noted. It is not known if these changes are
due to the fiber content of the seeds or a chemical component. Fenugreek has
been reported to increase the anticoagulant effect of warfarin. In a group of 10
women (non-placebo controlled) with infants born between 24 to 38.weeks
gestation (mean=29 weeks) who ingested 3 fenugreek capsules 3 times daily
(Nature’s Way) for a week, the average milk production during the week
increased significantly from a mean of 207 mL/day (range 57-1057 mL) to 464
mL/day (range 63-1140 mL). No untoward effects were reported. In a study of
26 mothers of preterm infants (less than 31 weeks gestation) compared the use
of fenugreek, 1725 mg (3 tablets) 3 times daily for 21 days to a placebo.
Mothers initiated pumping within 12 hours of delivery and kept a daily record.
Prolactin levels were drawn weekly and were not significantly changed. Data
analysis revealed no statistical difference between the mothers receiving
fenugreek or those receiving placebo in terms of milk volume. No adverse
effects were noted in mothers or infants. This study suggests that fenugreek is
probably ineffective. When dosed in moderation, fenugreek has limited toxicity
and is listed in the US as a GRAS herbal (Generally Regarded As Safe). A
maple syrup odor via urine and sweat is commonly reported. Higher doses
may produce hypoglycemia although this is largely unsubstantiated. A stimulant
effect on the isolated uterus (guinea pig) has been reported and its use in late
pregnancy may not be advisable. Fenugreek’s reputation as a galactagogue is
widespread but undocumented. The dose commonly employed is variable but
is approximately 2-3 capsules taken three times daily for a total daily dose of
no more than 6 grams. The transfer of fenugreek into milk is unknown,
untoward effects have only rarely been reported. Allergic reactions have
been reported in patients sensitive to chickpeas and peanuts.
Pregnancy Risk Category: POSSIBLY HAZARDOUS
Lactation Risk Category: L3
Adult Concerns: Maple syrup odor in urine and sweat. Diarrhea,
hypoglycemia, dyspnea (exaggeration of asthmatic symptoms). Once case of

suspected gastrointestinal bleeding in a premature infant has been reported.
Two cases of fenugreek allergy have been reported.
Pediatric Concerns: Maple syrup odor of infant urine.
Alternatives: Metoclopramide, domperidone
Reglan drug info from Medications and Mothers Milk
Metoclopramide, a dopamine receptor blocker, has multiple functions but is
primarily used for increasing the lower esophageal sphincter tone in
gastroesophageal reflux in patients with reduced gastric tone. In breastfeeding,
it is sometimes used in lactating women to stimulate prolactin release from the
pituitary and enhance breastmilk production. Since 1981, a number of
publications have documented major increases in breastmilk production
following the use of metoclopramide, domperidone, or sulpiride. With
metoclopramide, the increase in serum prolactin and breastmilk production
appears dose-related up to a dose of 15 mg three times daily.[1] Many studies
show 66 to 100 % increases in milk production depending on the degree of
breastmilk supply in the mother prior to therapy and maybe her initial prolactin
levels. Doses of 15 mg/day were found ineffective, whereas doses of 30-45
mg/day were most effective. In most studies, major increases in prolactin were
observed such as from 125 ng/mL to 172 ng/mL in one patient. In Kauppila’s
study, the concentration of metoclopramide in milk was consistently higher
than the maternal serum levels. The peak occurred at 2-3 hours after
administration of the medication. During the late puerperium, the concentration
of metoclopramide in the milk varied from 20 to 125 μg/L, which was less
than the 28 to 157 μg/L noted during the early puerperium. The authors
estimated the daily dose to infant to vary from 6 to 24 μg/ kg/day during the
early puerperium and from 1 to 13 μg/kg/day during the late phase. These
doses are minimal compared to those used for therapy of reflux in pediatric
patients (0.1 to 0.5 mg/kg/day). In these studies, only 1 of 5 infants studied had
detectable blood levels of metoclopramide; hence, no accumulation or side
effects were observed. While plasma prolactin levels in the newborns were
comparable to those in the mothers prior to treatment, Kauppila found slight
increases in prolactin levels in 4 of 7 newborns following treatment with
metoclopramide although a more recent study did not find such changes.
However, prolactin levels are highly variable and subject to diurnal rhythm,

thus timing is essential in measuring prolactin levels and could account for this
inconsistency. In another study of 23 women with premature infants, milk
production increased from 93 mL/day to 197 mL/day between the first and 7th
day of therapy with 30 mg/ day. Prolactin levels, although varied, increased
from 18.1 to 121.8 ng/mL. While basal prolactin levels were elevated
significantly, meto-clopramide seems to blunt the rapid rise of prolactin when
milk was expressed. Nevertheless, milk production was still elevated. Gupta
studied 32 mothers with inadequate milk supply. Following a dose of 10 mg
three times daily, a 66-100% increase in milk supply was noted. Of twelve
cases of complete lactation failure, 8 responded to treatment in an average of
3-4 days after starting therapy. In this study, 87.5% of the total 32 cases
responded to metoclopramide therapy with greater milk production. No
untoward effects were noted in the infants. In a study of 5 breastfeeding women
who were receiving 30 mg/day, daily milk production increased significantly
from 150.9 mL/ day to 276.4 mL/day in this group. Infant plasma prolactin
levels in breastfed infants were determined as well on the 5th postnatal day
and no changes were noted; thus, the amount of metoclopramide transferred in
milk was not enough to change the infants’ prolactin levels. In a study by Lewis
in ten patients who received a single oral dose of 10 mg, the mean maternal
plasma and milk levels at 2 hours was 68.5 ng/mL and 125.7 μg/L
respectively.[7] Hansen’s study showed that 28 women receiving 30 mg/day
had no significant increase in milk production as compared to the placebo
group.[8] However, this study was initiated with 96 hours of delivery, a time
when virtually all mothers would have had exceedingly high plasma prolactin
levels anyway. Metoclopramide should not be expected to work as a
galactagogue when plasma prolactin levels are high. It is well recognized that
meto-clopramide increases a mother’s milk supply, but it is exceedingly dose
dependent, and yet some mothers simply do not respond. In those mothers who
do not respond, Kauppila’s work suggests that these patients may already have
elevated prolactin levels. In his study, 3 of the 5 mothers who did not respond
with increased milk production, had the highest basal prolactin levels (300-
400 ng/mL). Thus it may be advisable to do plasma prolactin levels on underproducing
mothers prior to instituting metoclopramide therapy to assess the
response prior to treating. Side effects such as gastric cramping and diarrhea
limit the compliance of some patients but are rare. Withdrawing from Therapy:
It is often found that upon rapid discontinuation of the medication, the supply of
milk may in some instances reduce significantly. Tapering of the dose is

generally recommended and one possible regimen is to decrease the dose by
10 mg per week. Long-term use of this medication (>4 weeks) may be
accompanied by increased side effects such as depression in the mother
although some patients have used it successfully for months. The FDA has
warned that therapy longer than 3 months may be associated with tardive
dyskinesis. Two recent cases of serotonin-like reactions (agitation, dysarthria,
diaphoresis and extrapyramidal movement disorder) have been reported when
meto-clopramide was used in patients receiving sertraline or venlafaxine. [9]
Another dopamine antagonist, Domperidone, is a preferred choice but is
unfortunately not available in the USA other than in compounding pharmacies.
The US FDA recently issued a black box warning concerning the association
of Tardive Dyskinesia and the use of metoclopramide. But this warning is for
the use more than 3 months. Use for brief periods of up to 60 days is probably
safe in most instances.
Pregnancy Risk Category: B, B
Lactation Risk Category: L2
Adult Concerns: Diarrhea, sedation, gastric upset, nausea, tardive dyskinesia
(facial ticks) extrapyramidal symptoms, severe depression.
Pediatric Concerns: None reported in infants via milk. Commonly used in
pediatrics.
Drug Interactions: Anticholinergic drugs may reduce the effects of
metoclopramide. Opiate analgesics may increase CNS depression. Two cases
of serotonin-like syndrome have been reported when used with
metoclopramide. Two recent cases of serotonin-like reactions (agitation,
dysarthria, diaphoresis and extrapyramidal movement disorder) have been
reported when metoclopramide was used in patients receiving sertraline or
venlafaxine.
Relative Infant Dose Range: 4.7% - 14.3%
Adult Dose: 10-15 mg three times daily.
Alternatives: Domperidone

Domperidone drug info from Medications and Mothers Milk
Domperidone is a peripheral dopamine antagonist (similar to Reglan)
generally used for controlling nausea and vomiting, dyspepsia, and gastric
reflux. It blocks peripheral dopamine receptors in the gastrointestinal wall and
in the CRTZ (nausea center) in the brain stem and is currently used in Canada
as an antiemetic. Unlike metoclopramide (Reglan), it does not enter the brain
compartment and it has few CNS effects such as depression. It is also known to
produce significant increases in prolactin levels and has proven useful as a
galactagogue. Serum prolactin levels have been found to increase from 8.1
ng/mL to 124.1 ng/mL in non-lactating women after one 20 mg dose.
Concentrations of domperidone reported in milk vary according to dose. But
following a dose of 10 mg three times daily, the average concentration in milk
was only 2.6 μg/L. In a study by da Silva, 16 mothers with premature infants
and low milk production (mean= 112.8 mL/day in domperidone group; 48.2
mL/day in placebo group) were randomly chosen to receive placebo (n= 9) or
domperidone (10 mg TID) (n= 7) for 7 days.[4] Milk volume increased from
112.8 to 162.2 mL/day in the domperidone group and 48.2 to 56.1 mL/day in
the placebo group. Prolactin levels increased from 12.9 to 119.3 μg/L in the
domperidone group and 15.6 to 18.1 μg/L in the placebo group. On day 5, the
mean domperidone concentration was 6.6 ng/mL in plasma and 1.2 μg/L in
breastmilk of the treated group (n= 6). No adverse effects were reported in
infants or mothers. In a new study just released, a group of 6 breastfeeding
women were placed in a double blind randomized crossover trial to compare
doses of domperidone.[5] In this trial, mothers were studied in a run-in phase
(no drug treatment), 30 mg, or 60 mg domperidone daily doses (10 or 20 mg
every 8 hours). Milk volume created per hour, and plasma prolactin levels
were monitored. With milk production, two mothers did not respond to
domperidone treatment. Four other mothers showed a significant increase from
8.7 gm/ hour in the run-in phase to 23.6 gm/hour for the 30 mg/day dose, to
29.4 gm/hour for the 60 mg dose. While plasma prolactin levels were
increased by domperidone treatment, there was only a slight increase in milk
production at the 60 mg dose. Median domperidone concentrations in milk
were 0.28 μg/L and 0.49 μg/L for the 30 mg and 60 mg doses respectively. The
mean Relative Infant Dose was 0.012% at 30 mg daily and 0.009% at the 60
mg/day dose. The authors suggest that milk production increased at both doses
and there was a small trend for a dose-response. Forty-six mothers who had

delivered infants at

domperidone produces plasma levels many times higher than oral use.
Nevertheless, domperidone is known to prolong the QT interval of the heart in
some patients which is highly dose-related. Doses should be kept to less than
10-20 mg three to four times daily. There is no evidence that doses higher than
this increase prolactin levels above these lower doses, but they may
dramatically increase the risk of prolonged QT interval in patients. In addition,
a slow withdrawal is strongly recommended to prevent loss of milk
production, and a potential dysphoric withdrawal. Do not use in patients with a
preexisting prolonged QT interval.
Pregnancy Risk Category: C, C
Lactation Risk Category: L1
Adult Concerns: Dry mouth, skin rash, itching, headache, thirst, abdominal
cramps, diarrhea, drowsiness. Seizures have occurred rarely. Could induce
arrhythmias in hypokalemic patients, or patients subject to arrhythmias
(prolonged QT interval).
Pediatric Concerns: None reported in breastfed infants. Considered the ideal
galactagogue.
Drug Interactions: Cimetidine, famotidine, nizatidine, ranitidine (H-2 blocker)
plasma levels may be reduced by domperidone. Prior use of bicarbonate
reduces absorption of domperidone. Alfuzosin, artemether, chloroquine,
ciprofloxacin, ketoconazole, itraconazole, dil-tiazem, verapamil, grapefruit
juice, erythromycin, clarithromycin, dronedarone, gadobutrol, lumefantrine,
nilotinib, pimozide, quinine, tetrabenazine, thioridazine, ziprasidone,
amiodarone, arsenic trioxide, astemizole, bepridil, chloroquine,
chlorpromazine, cisapride, disopyramide, dofetilide, droperidol, halofantrine,
aloperidol, ibutilide, evomethadyl, mesoridazine, methadone, pentamidine,
pimozide, probucol, procainamide, sotalol, sparfloxacin, terfenadine enhance
QT prolonging effect of domperidone
Relative Infant Dose Range: 0.01% - 0.04%
Adult Dose: 10-20 mg 3-4 times daily

Alternatives: Metoclopramide
References
1. Thyroid hormone specifically inhibits prolactin synthesis and decreases prolactin messenger ribonucleic
acid levels in cultured pituitary cells. Maurer RA
2. Effects of Stress on Lactation: Chantal Lau, PhD*
3. Inadequate Milk Supply By Barbara Wilson-Clay, BSEd, IBCLC
4. Medications and Mothers Milk, 2012 Thomas W. Hale
Degrees
* BS in Pharmacy Southwestern Oklahoma State University (1968).
* Ph.D. in Pharmacology and Toxicology-University of Kansas, 1978.
Present Position Professor of Pediatrics Texas Tech University School of
Dr. Hale is an experienced clinical pharmacologist with many years of lecturing in all areas of
pharmacology and therapeutics. He currently is considered a leading expert in the use of medications in
breastfeeding women and travels world-wide lecturing on the topic of using medications in breastfeeding
mothers.
His four breastfeeding reference books, Medications and Mothers’ Milk, Clinical Therapy in Breastfeeding
Mothers and, Drug Therapy and Breastfeeding: From Theory to Clinical Practice, and A Medication Guide
for Breastfeeding Moms, are used throughout the world by physicians, nurses, NICUs, Obstetrical units,
Lactation Consultants, and LLLs.

Chapter 29
Reducing Milk Supply
Having too much milk can be as bad as not having enough, the problem is, no
one with sympathise with you. An oversupply really can’t be determined until
a baby is 2-3 weeks old, because as prolactin decreases, the supply decreases.
But, that doesn’t mean that you need to suffer and there is nothing we can do. I
do treat oversupply when needed, it is just done cautiosly because the last
thing we need is to dry up a mom’s milk. A delicate comprimise is possible, it
just has to be done right. Please refer to the section “Oversupply” for signs and
symptoms.
Drying up milk - Agressive
In a study of eight lactating women who received a single 60 mg dose of
pseudoephedrine, the 24 hour milk production was reduced by 24% from 784
mL/day in the placebo period to 623 mL/day in the pseudoephedrine period.
In a study of 3 lactating mothers who received 60 mg of pseudoephedrine, the
milk/plasma ratio was as high as 2.6-3.9. The average pseudoephedrine milk
level over 24 hours was 264 μg/L. The calculated dose that would be
absorbed by the infant was still very low (0.4 to.0.6%.of the maternal dose).
Pregnancy Risk Category: C, C
Lactation Risk Category: L3
Adult Concerns: Irritability, agitation, anorexia, stimulation, insomnia,
hypertension, tachycardia.
Pediatric Concerns: One case of irritability via milk. Reduced milk production
has been reported in late stage lactation. Mothers with marginal production
should avoid this medication.
Drug Interactions: May have increased toxicity when used with monoamine
oxidase inhibitors.
Relative Infant Dose Range: 4.7%

Adult Dose: 60 mg every 4-6 hours.
Alternatives: Oxymetazoline
B6- Less Aggressive
Ok, we have 2 different studies on B6 and the effect on prolactin. The first one
shows that B6 significantly suppressed prolactin, and one that shows that
relevant doses of vitamin B6 elevated plasma pyridoxal phosphate and breast
milk total vitamin B6 concentrations of lactating women without reducing
plasma prolactin concentration or halting lactation. So, although healthcare
professionals recommend this often, I do not have the evidence to say that this
will help.
Acupuncture
A more homeopathic option that my patients have reported success with.
Acupuncture has been clinically proven to boost blood prolactin level, and the
clinical use of acupuncture to promote lactation has also been demonstrated in
a randomized controlled study, so I would assume there are specific trigger
points to decrease prolactin. Unfortunately, I do not have a study to support it.
References:
1. Nutritionally relevant supplementation of vitamin B6 in lactating women: effect on plasma prolactin.
Andon MB, Howard MP, Moser PB, Reynolds RD
2. Effects of pyridoxine hydrochloride (vitamin B6) on chlorpromazine-induced serum prolactin rise in male
rats. Rosenberg JM, Lau-Cam CA, McGuire H
3. The influence of acupuncture on blood prolactin level in women with deficient lactation. Shanghai
Journal of Traditional Chinese Medicine, 1958, (12):557-558 [in Chinese].
4. Chandra A et al. [The influences of acupuncture on breast feeding production.] Cermin Dunia
Kedokteran, 1995, (105):33-37 [in Indonesian].
Medications and Mothers Milk, Thomas Hale, PHD

Chapter 30:
Plugged Ducts
I work with a lot of moms with plugged ducts, and I used to get plugged ducts
all of the time. A plugged duct may or may not turn into mastitis, but there is
seriously nothing worse than having milk trapped in your breast.
There are 2 types of plugged ducts. One is called a bleb, and it is a plug that
resembles a white head on your nipple. They usually start small, and over time,
can get larger and harder to treat. Some plugs on the nipple resemble an ulcer,
and the more you mess with them, the more they bleed.
Working with so many moms that have plugged ducts, I have tried everything to
decrease the amount of plugs that moms get. The best success that I’ve had in
preventing plugged ducts in my patients is a vitamin supplement called
Lecithin, and nipple exfoliation. What I recommend for every mom to do no
matter if they get plugged ducts or not, is to take a wet washcloth with them in
the shower, and gently exfoliate the nipples while they are in the shower.
Every shower, everyday. The most common plug that I see is a bleb.
A tiny bit of fat from the milk gets caught in the nipple opening, and can be
removed by putting pressure on both sides of the plug and extracting the fat like
popping a zit.

I also use a sterile needle sometimes; I like lancets that can be purchased at
any drug store. They are a teeny sterile needle that diabetics use to take blood
samples. I do not use the needle to poke the bleb, you will just bleed profusely
and cause more damage. You can use the needle to gently scrape off the skin
that has grown over the duct, and then squeeze the fat out.
Lecithin is a food supplement that seems to help some mothers prevent blocked
ducts. It may do this by decreasing the viscosity (stickiness) of the milk by
increasing the percentage of polyunsaturated fatty acids in the milk. It is safe to
take, relatively inexpensive, and seems to work in at least some mothers. The
dose is 1200 mg four times a day. If you are prone to plugged ducts, buy it and
take it everyday. You will see a decrease it the amount of plugs you get.

Chapter 31
Mastitis
What the heck is mastitis? Mastitis is one of the most common problems
reported in breastfeeding women, especially in the first 3-6 weeks postpartum.
Causes are: insufficient milk removal, stress and fatigue, sore or traumatized
nipples, and a prior history of infectious mastitis.
Technically, mastitis can be described as an inflammatory condition, which
may or may not be due to infection:
• Non-infectious mastitis
• Infectious mastitis
Basically if milk is trapped in the breasts, the tissue surrounding the stagnant
milk breeds bacteria. This bacteria is staph, and it’s pretty nasty. If you have a
plugged duct with no red patches on the breast and no fever,you would have
non-infectious mastitis. You will, however, feel very tired because the body is
starting to fight the infection that is growing, and you will feel stressed out that
the milk will not come out of that section of the breast. If you can remove this
source of the infection (the milk that’s trapped in the breast) the body has a
better chance of fighting the infection on its own. If you can’t get the milk out of
the breast, the mom will move on to infectious mastitis.
Things You Can Do
• Do NOT decrease or stop nursingwhen you have a plugged duct or
mastitis, as this increases risk of complications (including abscess).
• When unable to breastfeed, mom should express milk frequently and
thoroughly, preferably with a hospital grade double electric pump.
• Use warm compress or take a hot shower before nursing
• Anti-inflammatory Medication. Consult with your doctor first, but I
recommend 600mg of ibuprophin every 6 hours

• Loosen bra & any constrictive clothing to aid milk flow.
• Nurse on the affected breast first and keep the affected breast as empty as
possible. A baby’s suction is strongest in the beginning of a feed. Don’t
do this for a long period of time; we do not want to neglect the other
breast.
• Use breast compressions! Compress plugged area firmly while
breastfeeding or pumping, this will really help drain the breast from that
particular area that is clogged / infected.
Before antibiotics women died from mastitis, so it’s not something to take
lightly. Although penicillin-based antibiotics are regularly prescribed for
mastitis, there is a slight chance that the staff will be resistant to that class of
antibiotics.
Today, S. aureus has become resistant to many commonly used antibiotics. In
the UK, only 2% of all S. aureus isolates are sensitive to penicillin, with a
similar picture in the rest of the world. The lactamase-resistant penicillin’s
(methicillin, oxacillin, cloxacillin, and flucloxacillin) were developed to treat
penicillin-resistant S. aureus, and are still used as first-line treatment.
Methicillin was the first antibiotic in this class to be used (it was introduced in
1959), but, only two years later, the first case of MRSA was reported in
England. All Staphylococci are inherently resistant to naturally occurring, first
generation penicillin’s such as Penicillin V (penvee) or amoxicillin and
Zithromax (Z-Pak) would not be the drug of choice.
The antibiotic proven to be the most successful against mastitis is Bactrim, but
cannot be taken if you are allergic to sulfur based antibiotics. Keflex kills
penicillinase-producing, methicillin-susceptible staphylococci and
streptococci, but is not effective against MRSA. Certain antibiotics seem to
cause more yeast infections or overgrowth than others and cephalosporins such
as Keflex permit more yeast overgrowth.
Keflex works great, but it is more likely to cause an overgrowth of yeast in the
mom. You can speak to your doctor about getting a Diflucan prescription as a
preventative to take in conjunction with the Keflex, but if you start feeling
nipple pain or shooting pain in the breasts after taking the Keflex you would

want to be treated for thrush.
Your doctor can also do a culture for bacteria. It is very simple; they just need
a sample of your milk and a culture from the nipple. With a culture, a doctor
can determine the strain of bacteria and will know exactly what antibiotics to
prescribe you. Any doctor, including your OBGYN, can do the culture.
Reoccurring Mastitis
You probably don’t have mastitis “again”, especially if it is in the same breast.
It would be a good idea to get you on an antibiotic that is effective against S.
aureus, especially if you were prescribed Dicloxacillin the first time around.
Call your OBGYN and let them know your symptoms, and request a new
antibiotic. Bactrim is preferred due to its success rate. Don’t get upset about it,
it has happened to the best of us (including me!).
Methicillin-resistant S. aureus is one of a number of greatly feared strains of S.
aureus, which have become resistant to most antibiotics. MRSA strains are
most often found associated with institutions such as hospitals, but are
becoming increasingly prevalent in community-acquired infections. A recent
study by the Translational Genomics Research Institute showed that nearly half
(47%) of the meat and poultry in U.S. grocery stores were contaminated with
S. aureus, with more than half (52%) of those bacteria resistant to antibiotics.

Chapter 32
Therapeutic Ultrasound to treat Engorgement, Plugged
Ducts, and Mastitis
After getting mastitis 7 times in a row, I discovered therapeutic ultrasound
treatment for plugged ducts and mastitis. I am located in Southern California,
so for those of you far from me, I want to give you the information so that
hopefully you can find this ultrasound treatment in your area. This type of
ultrasound machine has been used in physical therapy since the 1950’s,
however, very few are aware of this use of ultrasound to treat blocked ducts.
An ultrasound therapist with experience in this technique has more successful
results.
Therapeutic Ultrasound has been used in physical therapy since 1955, mostly
for treatment of musculoskeletal pain, soft tissue injury and joint dysfunction,
or more recently, for accelerated tissue repair and wound healing, edema
reduction, and treatment of scar tissue.
How the Ultrasound Treatment Works
It provides a much deeper heat than a warm compress or shower is able to
provide
Pressure changes believed to break up blockage
Enhances inflammatory response and tissue repair
Most blocked ducts will be gone within about 48 hours. If your blocked duct
has not gone by 48 hours or so, therapeutic ultrasound often works. Most local
physiotherapy or sports medicine clinics can do this for you.
If two treatments on two consecutive days have not helped resolve the blocked
duct, there is no point in getting more treatments. Your blocked duct should be
re-evaluated by your doctor or at our clinic. Usually, however, one treatment is
all that is necessary. Ultrasound may also prevent recurrent blocked ducts that
occur always in the same part of the breast.

Dr. Jack Newman’s protocol is 2 watts/cm 2 continuous for five minutes to the
affected area, once daily for up to two treatments. I have seen the greatest
success with the following protocol: 2 watts/cm2 continuous, 1W/cm2 for 8
minutes followed immediately by 2 watts/cm2 continuous, 3W/cm2 for 8
minutes.
You won’t really feel anything when getting the ultrasound, other than warm. If
the intensity is set high, you may feel some tingling as you approach the nipple.
They key to treatment success is complete drainage from the affected breast
with a hospital grade electric breastpump immediately after ultrasound
treatment, and compression of breast in infected area to facilitate drainage.
Really grab, squeeze, and hold to empty the milk from the blocked area.
When Would You Use Therapeutic Ultrasound In Breastfeeding? To treat:
• Plugged Ducts
• Engorgement
• Mastitis that has already been or is being treated by appropriate antibiotics
Plugged Duct
• Will appear as an area of firmness or a knotty hard spot
• May or may not be tender
• May be red, but not accompanied by other signs of infection
• May notice decreased milk flow out of that particular area of the breast
Engorgement
• Swelling of the breast due to over-production of milk or decreased milk
consumption
• Full, firm, tender breasts that should soften with feeding/ pumping
• A temporary stage

Mastitis Symptoms
• Flu-like symptoms: fever, chills, body aches
• Breast is extremely painful, red, swollen, and warm
• Causes
• Chronic blocked ducts
• Stress/Fatigue
• Previous episodes of mastitis
• Cracked/painful nipples
Settings
• 1 MHz - US energy will penetrate to a depth of 2.5 to 5 cm
• 3 MHz - US energy will penetrate to a depth of .8 to 1.6 cm (Draper)
Intensity
• Acute condition: 1W/cm2
• Chronic condition: 3 W/cm2
Treatment Time
8 - 15 minutes

Chapter 33
Oversupply Syndrome / Foremilk Hindmilk Imbalance
Oversupply Syndrome is most often called “Foremilk Hindmilk imbalance.”
Signs of an oversupply:
• Baby is often is 1 pound or more over birth weight at 2 weeks of age
• Burps “like an adult”
• Spits up frequently, often appears to be large amounts.
• May have tentative diagnosis of Acid Reflux
• Gulps with feedings or appears to choke with letdown.
• Pulls off the breast frequently or chews at the breast
• Milk coming out of nose
• Nurses minimally on the second breast or refuses to take the second breast
after nursing well on the first breast
Many women now believe foremilk is “bad” milk and hindmilk is “good”
milk. Foremilk is GOOD! It is high in lactose, providing quick energy to the
infant, and the thanks to the internet, now mom’s are desperate to find a way to
reduce their infant’s foremilk intake. Lactose or milk sugar, is present all
milks, and lactose is the primary source of energy for the baby. The baby needs
lactose for proper growth and development.
First and foremost -- These babies almost always have major weight gain in
the first 3 months of life -- We normally see one pound (or more) weight gain
per week in these babies. If the baby isn’t gaining a lot of weight, oversupply
isn’t the entire problem.
Pumping some milk off at the beginning of a feeding, will appear to help
symptoms at first, but in the long run, it aggravates the problem by driving the

overall milk supply higher.
The early, aggressive, use of a breast pump to increase milk supply (so mom
has a freezer stash for when she returns to work) leads to induced oversupply.
In cases were we have calculated the number of ounces a baby needs per day
and then added the amount mom pumps, we find that the total milk supply can
equal double or triple the amount her baby actually needs.
Block Feeding is BAD. Block feeding is a recommendation given often, and
new moms are told to increase the duration on “one breast “ before switching
to the opposite side. The rationale is to use the body’s mechanisms to reduce
milk overproduction, but not removing milk from the other breast will lead to
the opposite problem, reducing mother’s milk supply. It is a sad day when I
have a patient that has to increase their milk supply after suffering from
oversupply and block feeding was recommended.
While one breast per feeding my be the physiologic model (women have 2
breasts because we occasionally have twins) using the same breast for
multiple feedings actually makes the problems worse because it increases the
foremilk load in the breast. The breast makes milk at a specific number of cc
or ounces per hour (typically about 3-4oz) and fat rich milk is made with
letdown.
Going longer than 6 hours on one breast is not “physiologically sound,” and
can cause a mother to lose an ample milk supply. Repeated engorgement will
lead to plugged ducts and mastitis (breast infection). Precautions to prevent
any potential complications need to be taught to the mother when any change in
natural feeding patterns is made. In addition, any other problems in mom or
baby are not addressed by increasing the length of time on one breast.
References:
1. The Content and Composition of BreastMilk From Melissa Kotlen Nagin February 25, 2008
2. Exp Physiol. 1993 Nov;78(6):741-55.
3. Paediatr Perinat Epidemiol. 2002 Oct;16(4):355-60.
4. Pediatrics. 2006 Mar;117(3):e387-95

Chapter 34
Nipple Vasospasm / Reynaud’s
This condition is due to a spasm of blood vessels preventing blood from
getting to a particular area of the body, typically the end of an extremity, though
not necessarily. They often occur in response to a drop in temperature.
Reynaud’s phenomenon will occur in the fingers, for example, when someone
goes outside from a warm house on a cool day. The fingers will turn white and
the lack of blood getting to the tips of the fingers will cause pain. Reynaud’s
phenomenon occurs more commonly in women than men, and can be often
associated with “auto-immune” illnesses such as rheumatoid arthritis.
Here, we will refer to both conditions as vasospasm. Vasospasm can also
occur in nipples. In fact, it is much more common than generally believed. It
can occur along with any cause of sore nipples, and is, in fact, probably a
result of damage, but it may also, on occasion, occur without any other kind of
nipple pain at all.
Typically, vasospasm occurs after the feeding is over, once the baby is already
off the breast. Presumably, the outside air is cooler than the inside of the
baby’s mouth. When the baby comes off the breast, the nipple is its usual color,
but soon, within minutes or even seconds, the nipple will start to turn white.
This is likely also due to drying of the nipple. Mothers generally describe a
burning pain when the nipple turns white. After turning white for a while, the
nipple may actually turn back to its normal color (as blood starts to flow back
to the nipple), and the mother will notice a throbbing pain.
The nipple may go back and forth between colors (and types of pain) for
several minutes or even an hour or two. Sometimes, the mother does not even
notice her nipple turning white and instead sees it change form pink to red to
purple and back to pink again. That the nipple changes color is not the concern;
that the mother is in pain is a concern. Interestingly some mothers do not have
pain with the vasospasm.
The treatment for vasospasm is to fix the original cause of the pain (we need to
rule out poor latch and thrush). Almost always, as the nipple soreness from
another cause is getting better, so will the pain from the vasospasm, but more

slowly. If the pain is mild, there may be no reason to treat. However, it is
worth treating when the pain is distressing, and especially if the pain during the
feeding does not improve, as severe restriction of blood supply to the nipple
may delay healing.
Plan of Care:
Diagnosis: Nipple Vasospasm / Reynaud’s
You are experiencing the pain in your nipple due to a nipple vasospasm. A
vasospasm hurts because you are experiencing a lack of blood flow to the
nipple.
1. Stop air-drying nipples. After your baby is done feeding, immediately cover
the nipple with your hand. Even after a shower, avoid getting out before your
nipples are completely covered with a towel.
2. Please take 100mg of a vitamin B6 complex twice per day.
3. Please take a magnesium supplement with added calcium. Please take
300mg of Magnesium and 200mg calcium 2 times daily.
4. If you are still in pain after trying these techniques for a few days, you
request a prescription of Nifedipine. One 30mg tablet of the slow release
formulation once per day for 2 weeks often takes away the pain of a
vasospasm.
Drug info on Nifedipine from Medications and Mothers Milk
Nifedipine is an effective antihypertensive. It belongs to the calcium channel
blocker family of drugs. Two studies indicate that nifedipine is transferred to
breastmilk in varying but generally low levels. In one study in which the dose
was varied from 10-30 mg three times daily, the highest concentration (53.35
μg/L) was measured at 1 hour after a 30 mg dose.[1] Other levels reported
were 16.35 μg/L 60 minutes after a 20 mg dose and 12.89 μg/L 30 minutes
after a 10 mg dose. The milk levels fell linearly with the milk half-lives
estimated to be 1.4 hours for the 10 mg dose, 3.1 hours for the 20 dose, and 2.4
hours for the 30 mg dose. The milk concentration measured 8 hours following a

30 mg dose was 4.93 μg/L. In this study, using the highest concentration found
and a daily intake of 150 mL/kg of human milk, the amount of nifedipine intake
would only be 8 μg/kg/day (less than 1.8% of the therapeutic pediatric dose).
The authors conclude that the amount ingested via breast milk poses little risk
to an infant. In another study, concentrations of nifedipine in human milk 1 to 8
hours after 10 mg doses varied from

Alternatives: Nimodipine

Chapter 35
Bacterial Infection of the Nipples
Unfortunately, when new mothers go to their doctor with nipple trauma,
healthcare providers often perceive that the trauma is due to a bad latch, not an
infection.
However, sore cracked nipples are so commonly colonized with bacteria in
the early postpartum period (54%).
The most common bacteria in the mouth is called Staphylococcus Aureus, and
studies show that there is a strong correlation between sore, cracked nipples
and S. Aureus colonization. When a mom has a bacterial infection on the
nipples, it commonly presents itself as sore and cracked nipples (commonly
described as a wound that will not heal) fissures are usually present, or a scab
that looks yellow (yellow crust). First, we should evaluate and make sure the
latch is good. If this baby is 6 months old, it is obvious that the latch is not the
issue. If the latch were bad, and caused wounds in the first few days, these
symptoms would appear when the baby is about a week old. Luckily treatment
is easy.
Nipple trauma and eczema of the nipples are associated underlying conditions
that can lead to duct infections. Nipple trauma leads to infections by disrupting
skin integrity. Studies show that mastitis developed in 12% to 35% of mothers
not treated with antibiotics when bacteria were present in a nipple wound.
Treatment Options
Ask doctor to culture for bacteria (especially helpful if you are taking oral
antibiotics) because you want to make sure you are taking the correct medicine.
Mupriocin 2% Ointment: Studies showed 16% improved with mupriocin
Studies showed 79% improved with oral antibiotics
The treatment really depends on how long the wound has been there. If it were
a fresh wound, a topical ointment like the Mupriocin would do the trick. If it is
advanced, your doctor should request an oral antibiotic that kills this type of

acteria. All Staphylococci are inherently resistant to naturally occurring, first
generation penicillins such as Penicillin V (penvee) or amoxicillin and
Zithromax Z-Pak.
The preferred antibiotic to use would be Bactrim, but can not be used if you
are allergic to sulfur based antibiotics. Keflex kills penicillinase-producing,
methicillin-susceptible staphylococci and streptococci, but is not effective
against MRSA. Certain antibiotics seem to cause more yeast infections or
overgrowth than others and cephalosporins such as Keflex permit more yeast
overgrowth.
References:
1. Amir LH, Pakula S. Nipple pain, mastalgia and candidiasis in the lactating breast. Aust N Z J Obstet
Gynaecol. 1991;31(4):378-380. Livingstone V, Stringer LJ.
2. The treatment of Staphylococcus aureus infected sore nipples: a randomized comparative study. J Hum
Lact. 1999;15(3):241-246.
3. Powers, N. Burning pain is not always yeast! ABM News and Views. 2000;6(2):12-13.

Chapter 36
Thrush
Statistically, Thrush (an overgrowth of yeast) is the #1 cause of nipple pain
after a baby is 2 weeks old. Does thrush harm my baby? No, thrush won’t kill
you, but it causes excruciating pain on a mom’s nipples and it is assumed that
that same pain is in the infant’s mouth. This pain will eventually cause a mom
to quit breastfeeding, and as the pain gets progressively worse, you wouldn’t
wish this pain on your worst enemy.
Here is the issue with treatment, there is no clear cut test to determine if you
have Thrush, and the yeast can be passed back and forth between mom’s
nipples and baby’s mouth. This is the most challenging issue, getting it
properly treated. If your baby has white on their tongue, put a sterile glove on
and try to wipe it off, or see if it disappears after a feeding. Think about if you
have been on any antibiotics or could be prone to yeast. When we take
antibiotics, it kills off all of the good and bad bacteria that can keep the natural
balance of yeast under control. You put that along with a warm wet
environment (leaking, wet pads, a warm mouth 8 times a day) this is already a
breading ground for yeast. It is like wearing a wet bathing suit 24 hours a day.
Nipples of breastfeeding mothers are virtually all contaminated with infant
saliva and the microbiological species present in the oral cavity of infants.
Numerous studies confirm that upward of 37% or more of 7-day old infants are
colonized with Candida (yeast), and 82% of infants have culturable C.
albicans (a diploid fungus that grows both as yeast and filamentous cells and a
causal agent of oral and genital infections in humans) at 4 weeks postpartum.16
Even newborns delivered vaginally have Candida present in their oral cavity
at 7 days. One study on the occurrence of Candida in asymptomatic dyads
found Candida in the oral cavity of 34.5% of predominately breastfed infants
and in 34.5% of lactating mothers’ breasts.
Symptoms of nipple yeast infection include sore nipples, red or pink nipples,
or burning nipples even when not feeding baby. Skin can look puffy, dry, or
flaky and as the yeast infection progresses, deep shooting breast pain during or
after feedings.

The yeast can begin to affect the nipple and make the skin around the nipples
very painful and hypersensitive. For example, if a t-shirt was to rub against the
nipples or the water of a shower would hit the nipples, this would hurt.
Because of the possibility the of chronic yeast infections in the breast, we
suggest mom’s nipples to be treated along with the babies treatment this will
usually prevent the yeast from taking hold on mom. The treatment normally
used for oral thrush is antifungal medicine. There is good research showing
that this treatment works in babies and children. It is used to treat children who
have thrush already, and also for prevention. This is the recommended first
course of treatment EVEN IF the baby is showing no symptoms:
Standard Plan of Care:
Diagnosis: Thrush
1. Based on the fact that you have been diagnosed with Thrush, a Diflucan
prescription will need to be called in for mom. The recommended dosage for
mother will be a loading dose of 400mg, followed by 200mg tablets a day for
at least 2 weeks.
2. Regardless if your baby is showing signs of Thrush (white patches on the
tongue or cheeks that does not wipe off) he can pass the yeast back and forth to
the nipples.Nystatin will most likely be the first treatment plan for your baby,
please speak to your pediatrician about obtaining a prescription. If symptoms
are severe, a Diflucan prescription is recommended. Studies show: “In another
study, all the babies treated with fluconazole liquid were cured after seven
days.[2] Out of those treated with nystatin, only a third were cured.”Goins RA,
Ascher D, Warcker N, et al. Comparison of fluconazole and nystatin oral
suspensions for treatment of oral candidiasis in infants. Pediatric Infectious
Disease Journal. 2002; 21: 1165-1167.
3. Please boil anything that comes in contact with your nipples or his mouth for
5 minutes each day for one week, once you begin treatment.
4. If your symptoms come back after the two week treatment, and your baby
was on Nystatin, speak to your pediatrician about a diflucan prescription for
your baby. The recommended dosage of DIFLUCAN for oropharyngeal

candidiasis in children is 6 mg/kg on the first day, followed by 3 mg/kg once
daily. Treatment should be administered for at least 2 weeks to decrease the
likelihood of relapse.
There has been some good research to show that these medicines work. One
large study found that nearly all the children with oral thrush who were
otherwise healthy got rid of the infection after using miconazole gel for 12
days. Only half of those who used nystatin liquid were cured. In another study,
all the babies treated with fluconazole liquid were cured after seven days. Out
of those treated with nystatin, only a third were cured.
Another large study looked at children who had oral thrush because their
immune system wasn’t working properly. It found that 9 in 10 children were
cured after being treated with fluconazole liquid. Half of those treated with
nystatin liquid were cured. In studies, the most common side effects of
antifungal medicines were vomiting and diarrhea. But fewer than 5 in 100
children got these problems.
Antifungals to prevent oral thrush
The best treatment to prevent oral thrush in children who have a weak immune
system seems to be a drug called fluconazole (Diflucan).
Drug info on Fluconazole from Medications and Mothers Milk
Fluconazole is a synthetic triazole antifungal agent and is frequently used for
vaginal, oropharyngeal, and esophageal candidiasis. Many of the triazole
antifungals (itraconazole, terconazole) have similar mechanisms of action and
are considered fungistatic in action. In vivo studies have found fluconazole to
have fungistatic activity against a variety of fungal strains including C.
albicans, C. tropicalis, C. glabrata, and C. neoformans. The pharmacokinetics
are similar following both oral and IV administration. The drug is almost
completely absorbed orally (>90%). Peak plasma levels occur in 1-2 hours
after oral administration. Fluconazole is transferred into human milk with a
milk/plasma ratio of approximately 0.85.[1] Following a single 150 mg dose,
milk levels at 2, 5, 24 and 48 hours were reported to be 2.93, 2.66, 1.76, and
0.98 μg/ mL respectively. Maternal plasma levels at 2, 5, 24, and 48 hours
were 6.4, 2.79, 2.52, and 1.19 μg/mL respectively.[1] The plasma half-life of

fluconazole is 35 hours and its breastmilk half-life is 30 hours. From these
data, and assuming an average milk level of 2.3 mg/L, an infant consuming 150
mL/kg/day of milk would receive an average of 0.34 mg/kg/d of fluconazole or
16% of the weight-adjusted maternal dose, and less than 5.8% of the pediatric
dose (6 mg/kg/day). In another study of one patient receiving 200 mg daily (1.5
times the above dose) for 18 days, the peak milk concentration was 4.1 mg/L at
2 hours following the dose.[2] However, the mean concentration of
fluconazole in milk was not reported. Taken together, these two studies suggest
a relative infant dose of 16 - 22% of the maternal dose.
Pregnancy Risk Category: C (D if given in high doses 400-800mg/day), C (D if
given in high doses 400-800mg/day)
Lactation Risk Category: L2
Adult Concerns: Adverse effects have only been reported in about 5-30% of
patients, and in these, only 1-2.8% of patients have required discontinuation of
the medication. Although adverse hepatic effects have been reported, they are
very rare, and many occur coincident with the administration of other
medications in AIDS patients. The most common complications include
vomiting, diarrhea, abdominal pain, and skin rashes.
Pediatric Concerns: Pediatric complications from oral ingestion include
gastrointestinal symptoms such as vomiting, nausea, diarrhea, abdominal pain.
Nephrotoxicity has not been reported. No complications from exposure to
breastmilk have found.
Drug Interactions: Decreased hepatic clearance of fluconazole results from use
with cyclosporin, zidovudine, rifabutin, theophylline, oral hypoglycemics
(glipizide and tolbutamide), warfarin, phenytoin, and terfenadine. Decreased
plasma levels of fluconazole have resulted following administration with
rifampin, and cimetidine.
Relative Infant Dose Range: 16.4% - 21.5%
Adult Dose: 50-200 mg daily.
Drug info on Nystatin from Medications and Mothers Milk

Nystatin is an antifungal primarily used for candidiasis topically and orally.
The oral absorption of nystatin is extremely poor, and plasma levels are
undetectable after oral administration.[1] The likelihood of secretion into milk
is remote due to poor maternal absorption. It is frequently administered
directly to neonates in neonatal units for candidiasis. In addition, absorption
into infant circulation is equally unlikely. Current studies suggest that
resistance to nystatin is growing.
Pregnancy Risk Category: C, C
Lactation Risk Category: L1
Adult Concerns: Bad taste, diarrhea, nausea, vomiting.
Pediatric Concerns: None reported. Nystatin is commonly used in infants.
Drug Interactions:
Relative Infant Dose Range:
Adult Dose: 500,000-1 million units three times daily.
Alternatives: Fluconazole
References
1. The Absence of Candida albicans in Milk Samples of Women with Clinical Symptoms of Ductal
Candidiasis Thomas W. Hale, Tiffany L. Bateman, Malcolm A. Finkelman, and Pamela D. Berens Hoppe
J, Burr R, Ebeling H, et al.
2. Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of
miconazole gel vs. nystatin suspension. Pediatric Infectious Disease Journal. 1997; 16: 288-293. Goins RA,
Ascher D, Warcker N, et al.
3. Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants.
Pediatric Infectious Disease Journal. 2002; 21: 1165-1167.
Flynn PM, Cunningham CK, Kerkering T, et al.
4. Oropharyngeal candidiasis in immunocompromised children: a randomized, multicenter study of orally
administered fluconazole suspension versus nystatin. Journal of Pediatrics. 1995; 127: 322-328.
5. Hoppe JE, Hahn H. Randomized comparison of two nystatin oral gels with miconazole oral gel for
treatment of oral thrush in infants. Antimycotics Study Group. Infection. 1996; 24: 136-139.

6. Ninane JA. Multicentre study of fluconazole versus oral polyenes in the prevention of fungal infection in
children with hematological or oncological malignancies. European Journal of Clinical Microbiology and
Infectious Diseases. 1994; 13: 330-337.

Chapter 37
Breastfeeding Twins
I work with a lot of twin mom’s. You know why? Because it is hard to
breastfeed twins! You have 2 kids, on two different schedules nursing all the
time, and you need to make a ton of milk. In order to breastfeed twins
exclusively, a mom would need to make 64oz of milk every 24 hours. It is best
to be prepared before the twins are born, because supplementation at birth is
almost always necessary. Because the first 2 weeks of breastfeeding is the
most important, we have the mom supplement on the breast the first week or so
with a long term SNS. A long term SNS is definitely preferred with twins,
although it is a little more expensive. Think of all of the money you will save if
you can nurse your twins for a year, about $10,000, so it is worth it.
Must have items:
• Twin Nursing Pillow
• Long Term SNS
• Nipple Shield
• Hospital Grade Breastpump Rental
A lot of twins are born to mothers that had issues with fertility, and most
require a prolactin boost immediately after birth. Please refer to the increasing
more milk section for information on hormonal imbalances. Here is the typical
plan of care for a prenatal appointment with a mom that is pregnant with twins:
Standard Plan of Care:
Prenatal Appt. with Twins
1. Breastfeeding is physical and hormonal, and based on the fact that you have
a hormonal imbalance that caused you to seek fertility treatments; we may need
to boost your prolactin (the hormone that tells your body to make milk) to make
sure you have an adequate milk supply.

2. Twins are more likely to be born early, and due to the fast that there is one
documented case of GI bleeding in a premature infant with the Fenugreek, I am
recommending speaking to your OBGYN about the use of Domperidone to
boost your prolactin levels.
3. The recommended dosage of Domperidone is 20mg, 4 times a day for 8
weeks. Breakfast, Lunch, Dinner and before bed are sufficient because you do
get a natural surge of prolactin when you are in REM sleep. After 8 weeks, you
can start tapering down the dosage over several days. The first dosages
recommended to eliminate are the one before bed, and the one first thing in the
morning. If you notice a decrease in your milk, bring up the dosage to the
original recommendations of 4 times per day. In order to get the adequate
nipple stimulation that you need, you will need to breastfeed or pump a
minimum of 8 times every 24 hours. If you have any mother baby separation,
please pump 8 times a day for 15 minutes, preferably with a hospital grade
breast pump.
4. For the first week, after the babies arrive and are breastfeeding, I am
recommending some additional pumping. Please pump directly after a feed for
15 minutes, at least 4 times a day.
5. Due to the fact that your babies will most likely be born earlier than 40
weeks, if they have issues latching, I am recommending using a nipple shield
each feed for a minimum of 2 weeks. Effective latching is very important for a
pre-term infant, so please use the nipple shield each time you breastfeed. Wash
the shield with warm soapy water in between feeds so it stays nice and sticky.
6. Instead of giving your babies a bottle, you can breastfeed and give extra
supplementation using the SNS. This will give you the confidence that they are
getting enough food and preserve your milk supply.
Things to pack for the hospital:
• Nursing Pillow
• Nipple Shields
• Breast pump and all equipment that goes with it

• Dishwashing Liquid
• Quick clean wipes to quickly clean pump parts

Chapter 38
Baby Feeding Requirements Chart
On or around day 3, when your milk increases in volume, this is how much
your baby will need to eat overall every 24 hours, and an average amount per
feed. This is a great reference for you, especially if you are going back to
work. You will know exactly how much milk you will need to leave in a
bottle.
As you can see, your baby will never need more than 32oz of milk a feeding,
until they are 6 months old. Even if they are 20lbs, the most food they will need
is 32oz per day. Keep in mind, bottle fed babies do eat about 30% more per
feeding. Don’t worry, breastmilk is 90% water and will not stretch the
stomach. If a breastfed baby eats too much, they will simply spit it back up.
Pounds Ounces
Required Milk (24 Milk Each Feed (8x
Hours)
day)
5 0 13.3 1.66 oz
5 1 13.5 1.68 oz
5 2 13.7 1.71 oz
5 3 13.8 1.72 oz
5 4 14 1.75 oz
5 5 14.2 1.77 oz
5 6 14.3 1.78 oz
5 7 14.5 1.81 oz
5 8 14.7 1.83 oz
5 9 14.8 1.85 oz
5 10 15 1.87 oz
5 11 15.2 1.9 oz
5 12 15.3 1.91 oz
5 13 15.5 1.93 oz
5 14 15.7 1.96 oz
5 15 15.8 1.97 oz
6 0 16 2 oz

6 1 16.2 2.02 oz
6 2 16.3 2.03 oz
6 3 16.5 2.06 oz
6 4 16.7 2.08 oz
6 5 16.8 2.1 oz
6 6 17 2.12 oz
6 7 17.2 2.15 oz
6 8 17.3 2.16 oz
6 9 17.5 2.18 oz
6 10 17.7 2.21 oz
6 11 17.8 2.22 oz
6 12 18 2.25 oz
6 13 18.2 2.27 oz
6 14 18.3 2.28 oz
6 15 18.5 2.31 oz
7 0 18.7 2.33 oz
7 1 18.8 2.35 oz
7 2 19 2.37 oz
7 3 19.2 2.4 oz
7 4 19.3 2.41 oz
7 5 19.5 2.43 oz
7 6 19.7 2.46 oz
7 7 19.8 2.47 oz
7 8 20 2.5 oz
7 9 20.2 2.52 oz
7 10 20.3 2.53 oz
7 11 20.5 2.56 oz
7 12 20.7 2.58 oz
7 13 20.8 2.6 oz
7 14 21 2.62 oz
7 15 21.2 2.65 oz
8 0 21.3 2.66 oz

8 1 21.5 2.68 oz
8 2 21.7 2.71 oz
8 3 21.8 2.72 oz
8 4 22 2.75 oz
8 5 22.2 2.77 oz
8 6 22.3 2.78 oz
8 7 22.5 2.81 oz
8 8 22.7 2.83 oz
8 9 22.8 2.85 oz
8 10 23 2.87 oz
8 11 23.2 2.9 oz
8 12 23.3 2.91 oz
8 13 23.5 2.93 oz
8 14 23.7 2.96 oz
8 15 23.8 2.97 oz
9 0 24 3 oz
9 1 24.2 3.02 oz
9 2 24.3 3.03 oz
9 3 24.5 3.06 oz
9 4 24.7 3.08 oz
9 5 24.8 3.1 oz
9 6 25 3.1 oz
9 7 25.2 3.15 oz
9 8 25.3 3.16 oz
9 9 25.5 3.18 oz
9 10 25.7 3.21 oz
9 11 25.8 3.22 oz
9 12 26 3.25 oz
9 13 26.2 3.27 oz
9 14 26.3 3.28 oz
9 15 26.5 3.31 oz

10 0 26.7 3.33 oz
10 1 26.8 3.35 oz
10 2 27 3.37 oz
10 3 27.2 3.4 oz
10 4 27.3 3.41 oz
10 5 27.5 3.43 oz
10 6 27.7 3.46 oz
10 7 27.8 3.47 oz
10 8 28 3.5 oz
10 9 28.2 3.51 oz
10 10 28.3 3.53 oz
10 11 28.5 3.56 oz
10 12 28.7 3.58 oz
10 13 28.8 3.6 oz
10 14 29 3.62 oz
10 15 29.2 3.65 oz
11 0 29.3 3.66 oz
11 1 29.5 3.68 oz
11 2 29.7 3.71 oz
11 3 29.8 3.7 oz
11 4 30 3.75 oz
11 5 30.2 3.77 oz
11 6 30.3 3.78 oz
11 7 30.5 3.81 oz
11 8 30.7 3.83 oz
11 9 30.8 3.85 oz
11 10 31 3.87 oz
11 11 31.2 3.9 oz
11 12 31.3 3.91 oz
11 13 31.5 3.93 oz
11 14 31.7 3.96 oz

11 15 31.8 3.97 oz
12 or
more lbs 32 4 oz

Day 1………. 1st 24 hours
Chapter 39
Breastfeeding Log - The First 2 Weeks
Goals: Breastfeeding at least 8 times, drink lots of water if you have swelling
in your feet, and watch for 1 wet and 1 poopie diaper (check to track). Poop
should look - black tarry
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 2………. 2nd 24 hours
Goals: Breastfeeding at least 8 times, drink lots of water if you have swelling
in your feet, and watch for 2 wet and 2 poopie diapers (check to track). Poop
should look - brownish/black tarry Breastfeeding start time
* Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.

Day 3………. 3rd 24 hours
Goals: Breastfeeding at least 8 times, watch for at least 3 wet and 3 poopie
diaper’s (check to track) and if you supplement, don’t forget to pump! Poop
should look - greenish (should be getting lighter)
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 4………. 4th 24 hours
Goals: Breastfeeding at least 8 times, and watch for at least 4 wet and 3-4
poopie diaper’s (check to track). If your baby is not getting enough, they will
not achieve this. If you supplement, don’t forget to pump! Poop should look -
greenish to yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.

Day 5………. 5th 24 hours
Goals: Breastfeeding at least 8 times, and watch for at least 5 wet and 3-4
poopie diaper’s (check to track). If your baby is not getting enough, they will
not achieve this. If you supplement, don’t forget to pump! Poop should look -
Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 6………. 6th 24 hours
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track).
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.

Day 7………. 7th 24 hours
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 8
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.

Day 9
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 10
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.

8.
Day 11
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 12
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.

7.
8.
Day 13
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.
6.
7.
8.
Day 14
Goals: Breastfeeding at least 8 times, and watch for at least 5-6 wet and 3-4
poopie diapers (check to track). If your baby is not getting enough, they will
not achieve this.
Poop should look - Yellow
Breastfeeding start time * Breast Last Fed On * Pee * Poop
1.
2.
3.
4.
5.

6.
7.
8.

Baby Friendly Designated Facilities as of November 2012
• Alameda County Medical Center, Oakland, CA
• Alice Peck Day Memorial Hospital, Lebanon, NH
• Arrowhead Regional Medical Center, Colton, CA
• Aurora Lakeland Medical Center, Elkhorn, WI
• Barstow Community Hospital, Barstow, CA
• Beaumont Hospital Grosse Pointe, Grosse Pointe, MI
• Boston Medical Center, Boston, MA
• Bridgton Hospital, Bridgton, ME
• BryanLGH Medical Center, Lincoln, NE
• Cambridge Birth Center, Cambridge, MA
• Cape Canaveral Hospital, Cocoa Beach, FL
• Capital Health Medical Center- Hopewell, Pennington, NJ
• Central Maine Medical Center, Lewiston, ME
• CentraState Medical Center, Freehold, NJ
• Community Hospital of Anaconda, Anaconda, MT
• Community Hospital of Anderson, Anderson, IN
• Community Hospital of San Bernardino, San Bernardino, CA
• Community Hospital of the Monterey Peninsula, Monterey, CA
• Concord Hospital, Concord, NH

• Corona Regional Medical Center, Corona, CA
• Culpeper Regional Hospital, Culpeper, VA
• Desert Regional Medical Center, Palm Springs, CA
• Dominican Santa Cruz Hospital, Santa Cruz, CA
• Enloe Medical Center, Chico, CA
• Evergreen Hospital Medical Center, Kirkland, WA
• Exempla Good Samaritan Medical Center, Lafayette, CO
• Fairview Hospital Cleveland, OH
• French Hospital Medical Center, San Luis Obispo, CA
• Glendale Memorial Hospital & Health Center, Glendale, CA
• Griffin Hospital, Derby, CT
• Gundersen Lutheran Health System, La Crosse, WI
• Hannibal Regional Hospital, Hannibal, MO
• Harbor-UCLA Medical Center, Torrance, CA
• Harlem Hospital Center, New York, NY
• Hartford Hospital, Hartford, CT
• Henry Mayo Newhall Memorial Hospital, Valencia, CA
• Hillcrest Hospital/Cleveland Clinic, Mayfield Heights, OH
• Hoag Memorial Hospital Presbyterian, Newport Beach, CA
• IU Goshen Hospital, Goshen, IN

• IU Health Ball Memorial Hospital, Muncie, IN
• IU Health Methodist Hospital, Indianapolis, IN
• IU Health-Bloomington, Bloomington, IN
• Jersey Shore University Medical Center, Neptune, NJ
• Kaiser Hospital
Orange County, Anaheim
Baldwin Park Medical Center, Baldwin Park, CA
Downey Medical Center, Downey, CA
Fontana Medical Center, Fontana, CA
Hayward Medical Center, Hayward, CA
Los Angeles, Los Angeles, CA
Moanalua Medical Center, Honolulu, HI
Panorama City Medical Center, Panorama City, CA
Riverside Medical Center, Riverside, CA
San Diego Medical Center, San Diego, CA
South Bay Medical Center, Harbor City, CA
Sunnyside Medical Center, Clackamas, OR
West Los Angeles, Los Angeles, CA
Woodland Hills Medical Center, Woodland Hills, CA
Sacramento Medical Center, Sacramento, CA
• Kootenai Medical Center, Coeur d’Alene, ID
• LAC + USC Healthcare Network, Los Angeles, CA
• Lakewood Hospital, Lakewood, OH
• Lisa Ross Birth & Women’s Center, Knoxville, TN

• Loma Linda University Children’s Hospital, Loma Linda, CA
• Madison Birth Center, Middleton, WI
• Maine General Medical Center, Waterville, ME
• Mary Hitchcock Memorial Hospital, Lebanon, NH
• Mayo Clinic Health System-Austin, Austin, MN
• Mayo Clinic Health System-Franciscan Healthcare, La Crosse, WI
• Mease Countryside Hospital, Safety Harbor, FL
• Medical Center of the Rockies, Loveland, CO
• MedStar Georgetown University Hospital, Washington, DC
• Melrose Wakefield Hospital, Melrose, MA
• Mercy Hospital Anderson, Cincinnati, OH
• Mercy Hospital Fairfield, Fairfield, OH
• Meriter Hospital, Madison, WI
• Middlesex Hospital, Middletown, CT
• Miles Memorial Hospital, Damariscotta, ME
• Mission Hospital, Asheville, NC
• Mission Hospital, Mission Viejo, CA
• Morton Plant Hospital, Clearwater, FL
• Naval Hospital Jacksonville, Jacksonville, FL
• Newport Hospital, Newport, RI

• Women’s Hospital, Chapel Hill, NC
• Northeastern Vermont Regional Hospital, St. Johnsbury, VT
• NYU Langone Medical Center, New York, NY
• Parkview Community Hospital Medical Center, Riverside, CA
• PeaceHealth Nurse-Midwifery Birth Center, Springfield, OR
• Pekin Hospital, Pekin, IL
• Poudre Valley Hospital, Fort Collins, CO
• Powell Valley Healthcare, Powell, WY
• Providence Alaska Medical Center, Anchorage, AK
• Providence Holy Cross Medical Center, Mission Hills, CA
• Providence Medford Medical Center, Medford, OR
• Providence Newberg Medical Center, Newberg, OR
• Reading Birth and Women’s Center, Reading, PA
• Regional Medical Center, Anniston, AL
• Richland Hospital, Richland Center, WI
• Riverside Community Hospital, Riverside, CA
• Robert E. Bush Naval Hospital Twentynine Palms, 29 Palms, CA
• Rochester General Hospital, Rochester, NY
• Rosebud Indian Health Service Hospital, Rosebud, SD
• Salinas Valley Memorial Healthcare System, Salinas, CA

• San Antonio Community Hospital, Upland, CA
• San Francisco General Hospital Medical Center, San Francisco
• Scripps Memorial Hospital Encinitas, Encinitas, CA
• SJH Elmer Hospital, Elmer, NJ
• South County Hospital, Wakefield, RI
• Southview Hospital, Dayton, OH
• St. Bernardine Medical Center, San Bernardino, CA
• St. Elizabeth Medical Center, Edgewood, KY
• St. John’s Hospital, Springfield, IL
• St. Joseph Hospital, Nashua, NH
• St. Joseph Hospital, Orange, CA
• St. Joseph’s Hospital Health Center, Syracuse, NY
• St. Joseph’s Medical Center, Stockton, CA
• St. Jude Medical Center, Fullerton, CA
• St. Mary Medical Center, Apple Valley, CA
• St. Vincent’s Medical Center, Bridgeport, CT
• Sutter Davis Hospital, Davis, CA
• Sutter Maternity & Surgery Center, Santa Cruz, CA
• Sutter Medical Center, Sacramento, Sacramento, CA
• Tacoma General Hospital, Tacoma, WA

• Tahoe Forest Hospital, Truckee, CA
• Texas Health Arlington Memorial Hospital, Arlington, TX
• Texas Health Harris Methodist Fort Worth, Fort Worth, TX
• Texas Health Harris Methodist HEB Hospital, Bedford, TX
• Texas Health Harris Methodist Hospital Cleburne, Cleburne, TX
• Texas Health Harris Methodist Stephenville, Stephenville, TX
• Texas Health Presbyterian Allen, Allen, TX
• Texas Health Presbyterian Hospital Plano, Plano, TX
• The Birth Center, Sacramento, CA
• The Hospital of Saint Raphael, New Haven, CT
• The Westerly Hospital, Westerly, RI
• Three Rivers Hospital, Brewster, WA
• Three Rivers Medical Center, Grants Pass, OR
• Tobey Hospital-Southcoast Hospital Group, Wareham, MA
• University of California, San Diego Medical Center, San Diego
• University of Minnesota Amplatz Children’s Hospital, Minneapolis, MN
• University of Utah Hospital, Salt Lake City, UT
• University of Washington Medical Center, Seattle, WA
• ValleyCare Olive View- UCLA Medical Center, Sylmar, CA
• Ventura County Medical Center, Ventura, CA

• Vidant Medical Center, Greenville, NC
• Weed Army Community Hospital, Ft. Irwin, CA
• Wheaton Franciscan Healthcare Elmbrook Hospital, Brookfield, WI
• Wheaton Franciscan Healthcare St. Francis Hospital, Milwaukee, WI
• Women’s Birth and Wellness Center, Chapel Hill, NC
• Women’s Health & Birth Center, Santa Rosa, CA
• Woodland Memorial Hospital, Woodland, CA
More information is available at www.babyfriendlyusa.org

Table of Contents
Title Page 2
Table of Contents 3
Introduction 6
The Barriers to Breastfeeding 9
How Long Should a Woman Breastfeed? 11
What is all of the hype on breastfeeding anyway? 14
The History of Infant Formula 15
The International Code of Marketing of Breastmilk
Substitutes
21
The Baby Friendly Hospital Initiative 23
The Affordable Care Act - Breastfeeding Services Are
Covered By Insurance!
24
The Benefits of Breastfeeding for Mom and Baby 26
Breastfeeding 101 / What You Really Need To Know 30
Preparation While You Are Pregnant 32
The First Stage of Lactation (Colostrum is Liquid Gold) 35
The Pamela Anderson Phase! The Second Stage of
Lactation
37
Infant States Proven By Research 39
The Crucial First 2 Weeks 46
Establishing A Milk Supply 47
The Breastfeeding Hormones - Oxytocin and Prolactin 49
Positioning and Latch – The Fundamentals of
Breastfeeding...
54
Nipple Shields 63

Tongue Tie 66
How To Supplement on the Breast 68
Jaundice 71
How Often Should I Be Breastfeeding 74
Fussy Baby 75
Food Protein Intolerance and Lactose Intolerance59 76
Acid Reflux 81
Burping 85
Pulling Off of the Breast / Biting 88
Engorgement 89
Increasing Milk Supply 90
Reducing Milk Supply 103
Plugged Ducts 105
Mastits 107
Therapeutic Ultrasound to treat Engorgement, Plugged
Ducts and Mastits
110
Oversupply Syndrome / Foremilk Hindmilk Imbalance 113
Nipple Vasospasm / Reynaud’s 115
Bacterial Infection of the Nipples 119
Thrush 121
Breastfeeding Twins 127
Worksheets: Baby Feeding Requirements Chart 130
Breastfeeding Log 135
Baby Friendly Designated Facilities as of November 2012 143