Posted by: Diana Cassar-Uhl, MPH, IBCLC | May 6, 2014

Insulin resistance and lactation insufficiency: FAQ


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As emerging research sheds light on possible reasons for lactation trouble even when mothers receive competent support, insulin resistance, or IR, is rising to the forefront of the discussion of possible causes. The following is an adapted-for-the-blogosphere excerpt of my upcoming book, Finding Sufficiency: Breastfeeding with Insufficient Glandular Tissue, which will be available this summer from Praeclarus Press. 

Can maternal body mass index be a warning sign for lactation trouble?

This question has been studied, and the answer is yes—maternal overweight has been identified as a potential risk factor for delayed onset of lactation (Chapman & Pérez-Escamilla, 1999), which can generate a snowball effect of early supplementation and poor breastfeeding management in those critical early hours and days. However, we are reminded that high BMI does not always predict lactation difficulty. Many women with a high body mass index go on to produce plenty of milk, even overproduce in some cases, and not all women with milk production issues have a BMI over 30, though it seems a growing percentage does. There is also scientific literature that suggests overweight or obesity during adolescence can affect pubertal development (Burt Solorzano & McCartney, 2010).

More research is needed to explore the possible relationship between adolescent body mass index, or, perhaps, adolescent diet and mammary gland development. Today’s new mothers grew up during what some call “the Snackwell’s era,” referring to a popular brand of snacks that were, as dietary recommendations of that time encouraged, processed to be low in fat. In order to be appealing, however, these products had—and perhaps still have—there are many “low fat” products still marketed as “healthy” foods even though current science suggests that dietary fat doesn’t cause body fat, more sugar and simple carbohydrates do—way more sugar than their regular-fat counterparts.

Does this matter for breast development?

A relevant study of rabbits examined the role of adolescent diet on mammary gland development during mid-pregnancy. Researchers fed an “obesogenic diet” (high fat, high sugar) to pre-pubertal rabbits, then compared their mammary gland development at mid-pregnancy to that of the rabbits fed the control diet. What they found was that the rabbits fed the high sugar diet had more rapid pubertal breast development, but lower capacity for lactation after the glandular development of pregnancy (Hue-Beauvais, Chavatte-Palmer, Aujean, Dahirel, Laigre, Pechoux, Bouet, et al. 2011). Longitudinal research on humans that measures nutritional status and dietary intake in pre-pubertal girls, then follows them into adulthood and examines such outcomes as weight status, reproductive axis functioning, and lactation, is sorely needed. For now, we can look to our rabbit friends for possibilities into what is going wrong for us.

Another consideration regarding higher BMI and lactation is the possible reduced effect of infant suckling on prolactin levels in the early days postpartum. Ostrum and Ferris (1993) found lower prolactin levels in mothers with insulin-dependent diabetes. These findings suggest that additional care should be taken to ensure these mothers have good control over their blood sugar, and are feeding their babies or stimulating their breasts appropriately and frequently. This is, of course, good guidance for all new breastfeeding mothers, but is of special importance for mothers with diabetes (who may or may not have a BMI > 30—it is the insulin dependence that seems significant here).

Through observation and study of over 1,000 mothers with lactation insufficiency, as well as a review of the available literature about glandular development and lactation, it becomes evident that the hormone insulin is a key player in this drama. The work of Marasco, Marmet, and Shell (2000) and West and Marasco (2008) has already informed the lactation support community of practitioners about the relationship between PCOS and breastfeeding problems—insulin resistance is part of that syndrome.

The Role of Insulin Resistance

Insulin resistance, which precedes type-2 diabetes, is a condition in which the body uses insulin (to regulate blood sugar) less effectively. More and more insulin is needed to regulate blood sugar, until, if not resolved, the body stops being able to produce enough insulin to keep blood sugar levels in a normal range (diabetes). A person might have insulin resistance for years before ever developing diabetes, and have no idea—insulin resistance is not always a condition with obvious symptoms.

A recent, groundbreaking study revealed that when a mother is insulin resistant, a particular gene is expressed more prominently than in insulin-sensitive individuals. This genetic expression suggests a relationship between insulin resistance and insufficient milk supply (Lemay, Ballard, Hughes, Morrow, Horseman, & Nommsen-Rivers, 2013). While not always comorbid—an individual can be insulin resistant and appear lean and thin, just as a person with higher BMI may be appropriately insulin sensitive and healthy—insulin resistance and high BMI are often seen together. But, does high BMI impair the ability of the existing glandular tissue to lactate properly, or was insulin resistance during puberty to blame for inadequate and incomplete development of the breast glands?

It is obvious that we are dealing with a very complex web of interdependent factors. One piece of the puzzle, which is related to high BMI, may be leptin, a hormone that is secreted by fat cells. Its short-term purpose is to regulate appetite and its long-term purpose is to regulate body weight. Brannian, Zhao, and McElroy (1999) also found that leptin may limit or inhibit the production of progesterone by the ovaries, but only when insulin was also present. If we think about what we know to be true–that regular, cyclic exposure to progesterone is necessary for glandular development, it makes sense that excess leptin plus excess insulin might result in insufficient progesterone each month to stimulate glandular growth of the breasts, even if ovulation and regular menstrual cycles are occurring.

How can I know if I have IR?

Insulin resistance is prevalent in Western societies and often goes unrecognized until type-2 diabetes emerges. In many people with insulin resistance, there are no outward symptoms. Some may have a condition called acanthosis nigricans, which is a darkening of skin either around the neck or in patches in places like the elbows, knees, knuckles, and armpits. Just over a decade ago, the means to assess for insulin resistance was complicated and difficult, requiring repeated blood samples over a period of a few hours to measure blood glucose, insulin, or both. A simple explanation of this procedure, called hyperglycemic (high blood sugar), hyperinsulinemic (high insulin), or euglycemic (normal blood sugar) glucose clamps, can be found at this link: http://www.diabeteshealth.com/read/2007/11/06/5500/whats-a-glucose-clamp-anyway/

While the glucose clamp techniques are the gold standard and the only way to assess exactly how insulin is being secreted and used in an individual’s body, recent and ongoing research has revealed simpler techniques for assessing insulin sensitivity, however, which technique offers the most precise and reliable result for which individuals varies widely. The labs that gave one mother a result might not be the same labs you need to get yours–there are several factors to consider and this is not a one-size-fits-all sort of thing.

All of these techniques for assessing insulin sensitivity use variables that should be easy to test for in a routine fasting blood test, such as triglyceride level, insulin, and glucose; as well as easily obtained values, such as waist circumference and body mass index (BMI). Assessments that have been compared to the euglycemic clamp technique include:

  • Fasting insulin level
  • Homeostasis model assessment (HOMA)
  • Insulin-to-glucose ratio
  • Bennett index
  • McAuley index

Your healthcare provider can help you determine which assessment will tell you about your insulin sensitivity. However, if you have had issues with blood sugar, including gestational diabetes, hypoglycemia, or high blood sugar at any time, it is probably safe to assume you may be insulin resistant and adopt a lifestyle that corrects this problem. Even if you’re not insulin resistant, a conscious diet and regular physical activity certainly won’t hurt, so trying to determine whether you are, indeed, insulin resistant may not really be all that important. If you are insulin resistant enough that it causes problems (for example, you do not ovulate), you should already be under the care of a physician who will recommend dietary changes, prescribe medication, or both. If you merely suspect insulin resistance, “acting as if” may improve your health and well-being in ways you didn’t even realize you were suffering. It’s worth a try.

So, Does Insulin Resistance Prevent Me from Making Milk? Can I Still Have IGT?

This is a complicated question, and another topic area where more research is definitely needed, because there are insulin resistant women who make plenty of milk (perhaps their pubertal breast development was robust?), and a confirmed relationship between insulin resistance and low milk output. We do know that insulin is important. Insulin has a direct action on the mammary gland during breast development and is vital to the production and secretion of colostrum (lactogenesis I), in lactogenesis II (when lots of milk arrives after the placenta is born, usually around day 2 or 3 postpartum), and continued lactation.

Berlato and Doppler (2009) examined the action of insulin and insulin-like growth factors on mammary gland development and the ability of those cells to secrete milk in mice. They found that particular cells in the breast must remain insulin sensitive to develop properly and function in the presence of other hormones of lactation. While this doesn’t address insulin and glandular development directly, it does provide some insight into why we might be seeing so much insulin resistance among mothers with full, but perhaps slightly hypoplastic-appearing breasts (see Huggins, Petok, and Mireles, 2000). It provides some support for what we know to be true about herbs and supplements that seem to help with milk production—they enhance blood sugar metabolism and insulin sensitivity.

Another mouse model that offers some insight is presented by Sun, Shushanov, LeRoith, and Wood (2011). These researchers found that when receptors for insulin-like growth factor were decreased (such as, perhaps, when there was too much insulin-like growth factor circulating during adolescent breast development), the body adapted by making fewer receptors, resulting in fewer alveoli (milk-making sites in the breast—glandular tissue). However, in the mice, this did not seem to have a significant effect on whether the mouse pups gained sufficient weight (which was how they measured sufficient milk output in the mice). The study does not account for whether the baby mice fed more frequently, or whether the dam’s (mamma-mouse’s) milk was somehow adapted to give her pups a better chance at survival.

So, there are likely some women with lactation trouble who are insulin resistant but have adequate glandular development, and others who are insulin resistant and have insufficient glandular development. It’s likely possible to have IGT and IR at the same time. There are also women without insulin resistance who have insufficient glandular development for other (theorized) reasons (this is covered further in my book, as well as in this blog post).

What Can I Do If I’m Insulin Resistant?

The problem most of us who’ve struggled with insulin resistance know all too well is that losing weight will help normalize insulin sensitivity, but being insulin resistant makes losing weight more challenging a task than it is for those who aren’t insulin resistant. It’s not as simple as “calories in, calories out,” and frustration comes quickly to a person who is eating meticulously (often feeling hungry all the time and fighting sugar cravings), and exercising through a feeling of sheer exhaustion, but seeing no results at all. Those who have been successful losing weight and beating insulin resistance have found that a counted-carbohydrate diet, perhaps difficult to get used to at first, can be very effective. Western culture’s portions of carbohydrate foods are quite large, much more than we need, and the message that we need a certain number of servings of whole grains every day is pervasive and misleading. If you ever had gestational diabetes, perhaps you were put on a daily eating plan that utilized this strategy to normalize blood sugar and insulin levels until your baby was born—three meals and two or three snacks, with prescribed carbohydrate counts. A nutritionist or dietician can help you determine what daily meal plan is best for you.

Look for ways to eat whole, real foods, and be wary of chemically engineered “food-like products,” such as artificial sweeteners, that may have fewer calories but often contain ingredients that can have a negative effect on overall health. A dietician or physician who works with insulin resistant patients can provide guidance. Will counting carbs or adopting a “paleo diet” definitely increase your milk production? There is some research to suggest that possibly, it could (Matsuno, Esrey, Perrault, & Koski, 1999; Mohammad, Sunehag, & Haymond, 2009). Clinical observations indicate that it probably won’t hurt your milk supply, and improved health is always a good idea. Whether this way of nourishing your body leads to improved health remains to be seen: there is also evidence to support improved overall health on diets that are nothing like the paleo diet. Perhaps different individual physiologies respond to different macronutrient balances? This is another area that needs more research.

Exercise

Along the same lines of good health, daily exercise is especially vital for those with insulin resistance. You don’t have to run a marathon: just 30 minutes each day of walking or other focused movement can help improve your insulin sensitivity and may improve your milk production over time. Even if your milk supply doesn’t seem to change, the daily exercise is indisputably good for your overall health, your mood, and your quality of sleep (even if your baby isn’t letting you sleep as much as you used to!), and sets a positive example for your child or children, who want to do everything you do.

Metformin

Many women with insulin resistance are prescribed metformin to normalize insulin sensitivity and keep blood sugar in a normal range. Some mothers have found that metformin, either through pregnancy, postpartum, or both, has improved their ability to make milk, and this makes a lot of sense given what we know about insulin and lactation. While anecdotal and clinical experience supports improvement in milk production for women with insulin resistance who start or resume metformin, Vanky and colleagues (Vanky, Nordskar, Leithe, Hjorth-Hansen, Martinussen, & Carlsen, 2012) reported after a randomized, controlled trial that metformin had no effect on breast changes/size increase in pregnancy or breastfeeding in women who were obese. However, in this study, the metformin was not continued after delivery, and this may (or may not) have been a factor in the outcome. If insulin is an issue for you, discuss your options with your doctor and the potential of these options to help you boost your milk production. Your milk supply troubles may be the only “symptom” you have that something else is not working properly in your body.

Myo-inositol

Metformin is not well-tolerated by all women. Many stop taking it because the side effect of gastro-intestinal distress/diarrhea interferes with daily life too much. There is another option that may be promising for insulin-resistant mothers, and it may also improve ovarian function in women with PCOS. Myo-inositol, a naturally occurring substance that our bodies produce, that is also available in foods (a member of the B-complex vitamin group) like beans, fruits, and nuts, has been shown to have an effect on how our insulin receptors work. Gerli, Papaleo, Ferrari, and DiRenzo (2007) found that myo-inositol helped women with PCOS who were not ovulating to begin ovulating again (in women with a BMI under 37). The study also noted weight loss among those who were taking the myo-inositol (the experimental dose was 4 grams per day, which is 8 500mg capsules), but weight gain among the placebo group.

Another study (Artini, DiBerardino, Papini, Genazzani, Simi, Ruggiero, & Cela, 2013) offered similar positive results on ovarian function, as well as improvement of insulin sensitivity in women with PCOS who were taking myo-inositol (in this study, the dosage was only 2g per day). Myo-inositol, in very high doses, has also been shown to help with the treatment of obsessive-compulsive disorder and depression (Brink, Viljoen, deKock, Stein, & Harvey, 2004), which may be of interest to women who bear the dual suffering of lactation difficulty and depressive illness.

It is important to note that myo-inositol has not been formally studied in pregnancy but, due to its observed ability to stimulate oxytocin release, may cause uterine contractions. The ideal time to see if this supplement might benefit you is not when you are pregnant, but before you become pregnant. Along those lines, it is decidedly more advisable to improve any insulin issues you may have before you become pregnant. It is wise to find a healthcare practitioner you trust and discuss options like myo-inositol with him or her. Often, printing out an abstract to a study (such as those cited here), and bringing it to your doctor or midwife can prompt her to explore an option that might be new, but beneficial to you.

Hopefully, this post offers a primer for your future discussions with your healthcare providers as you try to solve the mystery of your lactation issues. I encourage you to more thoroughly examine the resources that are cited in this post, and to share the ones that seem relevant to your situation with your healthcare provider.

References:

Artini, P. G., DiBerardino, O. M., Papini, F., Genazzani, A. D., Simi, G., Ruggiero, M., & Cela, V. (2013, Jan 22). Endocrine and clinical effects of myo-inositol administration in policystyc ovary syndrome. A randomized study. Gynecological Endocrinology. Advance online publication. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23336594

Berlato, C., & Doppler, W. (2009). Selective response to insulin versus insulin-like growth factor-I and -II and up-regulation of insulin receptor splice variant B in the differentiated mouse mammary epithelium. Endocrinology, 150(6), 2924-2933. doi: 10.1210/en.2008-0668

Brannian, J. D., Zhao, Y., & McElroy, M. (1999). Leptin inhibits gonadotrophin-stimulated granulosa cell progesterone production by antagonizing insulin action. Human Reproduction, 14(6), 1445-1448. doi: 10.1093/humrep/14.6.1445

Brink, C. B., Viljoen, S. L., deKock, S. E., Stein, D. J., & Harvey, B. H. (2004). Effects of myo-inositol versus fluoxetine and imipramine pretreatments on serotonin 5HT2A and muscarinic acetylcholine receptors in human neuroblastoma cells. Metabolic Brain Disease, 19(1-2), 51-70.

Burt Solorzano, C. M., & McCartney, C. R. (2010). Obesity and the pubertal transition in boys and girls. Reproduction, 140(3), 399-410. doi: 10.1530/REP-10-0119

Chapman, D. & Pérez-Escamilla, R. (1999). Identification of risk factors for delayed onset of lactation. Journal of the American Dietetic Association, 99(4), 450-454.

Gerli, S., Papaleo, E., Ferrari, A., & DiRenzo, G. C. (2007). Randomized, double blind placebo-controlled trial: Effects of myo-inositol on ovarian function and metabolic factors in women with PCOS. European Review for Medical and Pharmacological Sciences, 11(5), 347-354.

Hue-Beauvais, C., Chavatte-Palmer, P., Aujean, E., Dahirel, M., Laigre, P., Pechoux, C., Bouet, S. … Charlier, M. (2011). An obesogenic diet started before puberty leads to abnormal mammary gland development during pregnancy in the rabbit. Developmental Dynamics, 240(2), 347-356.

Huggins, K. E., Petok, E. S., & Mireles, O. (2000).  Markers of lactation insufficiency: A study of 34 mothers. Current Issues in Clinical Lactation. Sudbury, MA; Jones & Bartlett, 25-35.

Lemay, D. G., Ballard, O. A., Hughes, M. A., Morrow, A. L., Horseman, N. D., & Nommsen-Rivers, L. A. (2013). RNA sequencing of the human milk fat layer transcriptome reveals distinct gene expression profiles at three stages of lactation. PLoS One, 8(7), e67531. doi: 10.1371/journal.pone.0067531

Marasco, L., Marmet, C., & Shell, E. (2000).  Polycystic ovarian syndrome: A connection to insufficient milk supply? Journal of Human Lactation, 16(2), 143-148.

Matsuno, A. Y., Esrey, K. L., Perrault, H., & Koski, K. G. (1999). Low intensity exercise and varying proportions of dietary glucose and fat modify milk and mammary gland compositions and pup growth. Journal of Nutrition, 129, 1167-1175

McAuley, K. A., Williams, S. M., Mann, J. I., Walker, R. J., Lewis-Barned, P. J., Temple, L. A., & Duncan, A. W. (2001). Diagnosing insulin resistance in the general population. Diabetes Care, 24(3), 460-464.  Retrieved from http://care.diabetesjournals.org/content/24/3/460.full#T3

Mohammad, M. A., Sunehag, A. L., & Haymond, M. W. (2009). Effect of dietary macronutrient composition under moderate hypocaloric intake on maternal adaptation during lactation. American Journal of Clinical Nutrition, 89(6), 1821-1827. doi: 10.3945/​ajcn.2008.26877

Ostrum, K. M., & Ferris, A. M. (1993). Prolactin concentrations in serum and milk of mothers with and without insulin-dependent diabetes mellitus. American Journal of Clinical Nutrition, 58(1), 49-53.

Sun, Z., Shushanov, S., LeRoith, D., & Wood, T. L. (2011). Decreased IGF type 1 receptor signaling in mammary epithelium during pregnancy leads to reduced proliferation, alveolar differentiation, and expression of insulin receptor substrate (IRS)-1 and IRS-2. Endocrinology, 152(8), 3233-3245. doi: 10.1210/en.2010-1296

Vanky, E., Nordskar, J. J., Leithe, H., Hjorth-Hansen, A. K., Martinussen, M., & Carlsen, S. M. (2012). Breast size increment during pregnancy and breastfeeding in mothers with polycystic ovarian syndrome: A follow-up study of a randomized controlled trial on metformin versus placebo. BJOG: An International Journal of Obstetrics and Gynaecology, 119(11), 1403-1409. doi: 10.1111/j.1471-0528.2012.03449.x

West, D. & Marasco, L. (2008). The breastfeeding mother’s guide to making more milk. New York: McGraw-Hill.

 

Posted by: Diana Cassar-Uhl, MPH, IBCLC | December 2, 2013

On mothers, mammograms, and moving on


It was a simple enough text message from my husband, who is holding down the fort at home in New York while I’m working in a public health fellowship in Washington, DC.

“Forgot to tell you, a nurse from Keller called. Said you are due for mammogram. Said you can call radiology directly to schedule.”

It makes perfect sense. I turned 40 in April and it’s December now, so the call shouldn’t come as a surprise. What is surprising, though, is that upon reading the text, I instantly fell apart and was consumed by my own sobs and tears. Why is there so much emotion wrapped up in the idea that it’s time for me to get a routine breast screening?

I think back to January of 2003, nearly 11 years ago. I was sitting on the exam table in the oh-so-flattering paper gown at my 6-week postpartum checkup with my OB/GYN at the Army hospital. My infant, who hardly slept the first three years of her life, snoozed in her car seat on the floor, allowing me to have a conversation with the doctor.

“There’s this lump here,” I showed her. “I think it’s a galactocele.” I wasn’t yet a lactation expert, but I had read up enough about breast abnormalities to realize that a bean-sized lump that only appeared in the same place when my breast filled between feedings was probably just a little pocket of milk. She agreed, then asked me, “how’s your mom doing?” I had learned a few weeks before my baby was born that my mother had breast cancer—estrogen receptor-positive cancer. It was detected early and hadn’t spread, but she had begun taking Tamoxifen, per the protocol for that kind of cancer.

She was also preparing to move 700 miles away from me the following week. I was a first-time mother with a baby who didn’t sleep; I was going back to a job I didn’t really miss in a month and I hadn’t yet found “suitable” childcare (who was going to replace me? I couldn’t fathom leaving my baby anywhere!); my mother, who lived 20 minutes away from me since I graduated from college over 7 years prior, was moving 700 miles away from me; and she had cancer.

Mom’s oncologist suggested I would want to get a baseline mammogram when I turned 30, less than 4 months ahead. “You’d have to quit breastfeeding to do that,” my doctor said, “but since breastfeeding is supposed to be protective for both you and your daughter, you might as well just get the mammogram whenever you wean naturally.”

I doubt anyone suspected that I’d be breastfeeding children continuously for the next decade—I know I didn’t. There was a study being conducted at the facility where I got my medical care; it was about the efficacy of bioelectric impedance imaging in early detection of breast cancer. The recruiting nurse, after a few years, finally stopped approaching me in the waiting rooms at my childrens’ well-child visits. Instead, she smiled and simply said “not weaned yet, right?” Around my 38th birthday, at my annual checkup, it was suggested to me that I get a mammogram—or even a simple ultrasound image—regardless of the fact that I was still lactating, because my mother was unsure but thought one of her doctors told her she was a carrier of a mutated BRCA gene. If she is (if I am), my risk for developing cancer is disproportionately high. I called around to facilities that should have had a radiologist on hand who could read an image of a lactating breast, but came up empty. In the midst of a career change and dealing with a major medical procedure for one of my children, I gave up trying to get either a baseline image of my breasts or a genetic test for the BRCA mutations. Neither was coming easily and I was tired.

Fast-forward a few more years. My youngest daughter has weaned, I believe. I would be more definite about saying so but, with her 6th birthday approaching this week, she’s still not admitting to having weaned. It’s been a good year and a half since I’ve had any milk, and her weaning has been so gradual that I’ve wondered for over a year whether each time she latched on was going to be her last. I thought she was all done this summer, but she nursed a few more times this fall after my week-day move to Washington. It was only 15 seconds on one side—definitely more for her peace of mind that she could nurse if she wanted to—but I struggled with whether I was still a breastfeeding mother.

The call to get my mammogram holds all of this within it. I’m 40 now; maybe the recommendations are antiquated and maybe the evidence isn’t really supportive of the practice but 40 year-old women get a mammogram. I can face my chronological age with confidence knowing that I’ve employed so many known protective factors over the last 20 or so years: regular exercise, healthy diet, and lots of breastfeeding; but my mother’s history nudges me to remember that sometimes, there isn’t a way to outrun risk.

What makes my heart the heaviest, though, is that, when I present myself for imaging of my breasts, I’m conceding—really, truly conceding that my breastfeeding days are over. I’m no longer lactating, I have no more reason to delay that baseline image. I’m in a new season as a mother, and it’s a wonderful, fun season of children who use toilets (mostly) by themselves, who can appreciate a nice meal at a decent restaurant and be pleasant company during it, who have interests and activities that I love participating in with them. I embrace that things are as they should be, but I can’t promise I won’t cry a little when I report for that mammogram—confronting my advancing age, a family history that’s a little bit scary, and the defining chapter of my life that is now undeniably closed.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | August 6, 2013

Why I didn’t celebrate World Breastfeeding Week this year


World Breastfeeding Week, which takes place during the first week in August each year, is almost over—I managed to make it 6 days without blogging, organizing an event, or otherwise going all out to promote breastfeeding during this very special week. I’m an IBCLC. I’m supposed to be all over this week, right?

The sun is setting on my time as a breastfeeding mother.

The sun is setting on my time as a breastfeeding mother.

I became an IBCLC in 2009, but my breastfeeding story started in December of 2002. I began my breastfeeding journey with one flat and one inverted nipple, a baby who became severely jaundiced by her 18th hour of life due to ABO incompatibility and the Coombs antibody, and hospital practices that were less than supportive of getting breastfeeding off to the best start. When my first baby and I were discharged from the hospital on her 7th day, I had enough pumped milk with us to last several weeks; yet, the nurse’s words (which were no doubt meant to encourage me) “lots of mothers just pump and bottle-feed, it’s no big deal,” upset me tremendously. I was determined to get this breastfeeding thing right. No one else in my family had successfully breastfed, but my little girl seemed to know she belonged at my breasts—every time I picked her up to hold her, she bobbed her tiny little head against my chest. I was going to get this right.

I was fortunate to get some skilled, compassionate help and when my baby finally latched onto me on her 8th day, we never looked back. She breastfed until a few weeks before she started her 2nd year of preschool; she was almost 4. This meant that I had been tandem nursing her and her younger brother for nearly two years—he was born before her 2nd birthday. About 7 months after his big sister weaned, my son again shared his “uns,” this time with my 3rd baby, who was growing inside of me. I would tandem nurse them until just before my son’s 4th birthday, as well.

I had been in something of a hurry to encourage—albeit gently—my first two children to wean, since I didn’t love tandem nursing. Oh, I wouldn’t have done anything different if given the chance for a do-over, but breastfeeding a baby and a toddler, or a toddler and a preschooler as they got older, was a lot for me. I’m thankful I had support and the ability to allow both of them to wean more or less on their own schedules, but frequent conversations and a special “weaning lunch” out with me helped bring those two breastfeeding relationships to a close.

Things were different with “baby number last,” though. I don’t know if knowing she was the last one or appreciating the significance of breastfeeding as a parenting tool made me want to linger with her more than I did with the older two. Maybe it was because she took such obvious comfort in nursing, or, due to the fact that she was an avid thumb-sucker, she never really lost her ability to nurse properly—the other two got lazy latches and stopped transferring milk when they neared the end of their time breastfeeding, but my youngest didn’t.

I was relieved when her 4th birthday came and went and she hadn’t weaned, because we were preparing for a major surgery. I was truly surprised last summer when, at 4-1/2, she went to visit her grandparents for a week without me and came back wanting to nurse. The leaves began falling off the trees and I started wondering which nursing session would be our last—the end had to be near, didn’t it? Her 5th birthday passed, and I asked her, “do you think you’re going to wean, soon?” Even if it had been a few days since her last nursing, she would always nurse sometime that day if I asked her about weaning, letting me know that she was decidedly against the idea.

During her 2nd half of kindergarten, I had little or no milk left. Gabriella rarely asked to nurse anymore, and my body knew that winter had arrived—there would be no more new life in my breasts once they went dormant. This was an entirely new experience for me, since I had never really gone through a weaning on my end before. I wondered if I’d lose weight? Gain weight? Would my bras fit anymore? I had heard so many stories of the physical changes mothers experienced. I didn’t know which ones might apply to me, having breastfed continuously for over a decade. Some colleagues told me I would be able to express drops of milk “maybe forever,” but this didn’t seem to be the case for me. Gabriella would latch on once every few weeks this past spring, just for a few seconds. “Is there any milk in there?” I’d ask her. “No, but I still like the taste of your boobie,” she’d say with a giggle and a smile.

I wasn’t really sure what she was getting from those 15-second latches once or twice a month, and I also didn’t actually know what to say when anyone asked me if I was still breastfeeding (though these inquiries had become very, very infrequent because few people—including myself—imagined I’d still be nursing a kindergartener!). We were in an unfamiliar gray area. During a morning snuggle, I asked Gabriella “did you wean?” She answered “no, but I don’t nurse in the mornings anymore.” A few weeks later, I asked her again, during a bedtime snuggle. “Did you wean?” “Ummm, no,” she explained. “I don’t nurse at night anymore. But I’m not weaned.”

About a month ago, after I finished grad school and we were enjoying a rare (OK, the first) phase of downtime in our family life, I snuggled up with Gabriella on our “milk chair,” a rocker/recliner where a lot of breastfeeding had taken place over the years. Even at 5-1/2, she’s still so affectionate and snuggly. She tells me I’m the most beautiful mommy on the whole earth. I want to know why she doesn’t want to say she’s weaned. She tells me, in a tone of voice that sounds downright scholarly, “I just haven’t made that decision yet.” I stress to her, and to myself I think, that we can always be close, even when we’re not nursing. I remind her that I haven’t had milk in months, and that she doesn’t nurse in mornings or nights anymore. Isn’t this weaning? Haven’t we weaned?

That night, as if on cue, Gabriella sighs “I wish I could nurse” while I’m tucking her into her bed for the night. “You can if you want,” I reply, and she is happy. She latches on to my empty breast for a few seconds, pops off, and tells me “I’m done. I don’t need the other one.”

I find I’ve gotten tired of wondering whether the last nursing session has passed or is yet to come. I’ve accepted that I’m no longer lactating, and with my first baby preparing to enter the 6th grade in a few weeks, I’m not worried about whether I know how to connect with a weaned child—I know I do. With or without Gabriella’s consent, I think I’ve closed the “breastfeeding mother” chapter of my life, content instead to serve other breastfeeding mothers the best I know how. This is a big shift for me, since I’ve never approached breastfeeding support other than from the perspective of a mother who is also “walking the walk.” Am I “over” breastfeeding? The truth is, today, I’m ambivalent about it. My celebration of World Breastfeeding Week will always be welcome—I will never not be a supporter or an advocate, but a decade is a long time to do something, to do anything. A decade is a long time to be a breastfeeding mother; to not be one anymore, without ceremony or the closure that a more formal ending might offer, leaves me a bit unsettled.

Then it occurs to me: just as my children have each weaned with the assurance and safety that I would still be their home base—our relationship would be strong on the foundation breastfeeding established for us—I, too, could assuredly move into the next chapter of motherhood, and of breastfeeding support. I no longer have milk to offer, but after nearly 11 years of mothering, I have so much more to offer my children … and the mothers I support. This World Breastfeeding Week has been a bittersweet one for me, a commencement of sorts; I proudly move away from the behavior I joyfully allowed to define who I was as a mother, and I embrace the confidence and wisdom I gained through breastfeeding my children, knowing I’m ready for whatever is next for us.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | February 22, 2013

Breastfeeding with mammary hypoplasia/IGT: a study!


breastfeeding

One of our biggest frustrations in the lactation/breastfeeding support arena is that we have so little information to offer mothers who have a physiological barrier to breastfeeding — their bodies just don’t produce milk, even after other problems have been solved.  I described this condition in this post at KellyMom.com.

Penny Liberatos, PhD (New York Medical College) and I have finished collecting responses for this study, which sought to understand the relationship between various factors and breastfeeding/lactation outcomes for mothers with insufficient glandular tissue.

Thank you to everyone who participated in this study — data analysis and manuscript preparation are underway.  The time and care that went into each response is evident and is immensely appreciated. We will be sure to share where and when our findings may be published.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | September 24, 2012

Milksharing: a story of peace and healing


If you’ve visited my blog before, you know that I believe in human milk for human babies, and I have a deep understanding and empathy for those mothers who can’t or choose not to breastfeed their babies, for whatever reason.  This week, World Milksharing Week, offers a perfect opportunity to highlight a beautiful story of love and healing, of generosity and peace that have been made possible by the gifts of milk donors.

First, be sure to check out this comprehensive report about mother-to-mother milksharing, by Amber McCann, IBCLC, and, from the International Breastfeeding Journal, Milk sharing: from private practice to public pursuit.

Stephanie was heartbroken after her first baby, Isaiah, was born and she realized she couldn’t make enough milk to meet his nutritional needs and sustain his growth.  A condition called mammary hypoplasia/insufficient glandular tissue (IGT) made it so that she could only produce about 4 ounces of milk each day; she had to supplement Isaiah’s intake with something other than her own milk, and at the time, commercially-prepared baby milk (formula) was, as far as she knew, her only option.  “I knew there was such a thing as donor breastmilk, but I thought it was only for sick babies,” Stephanie explains.  “We supplemented with just about every formula under the sun,” Stephanie recalls.  Isaiah had an undiagnosed cow’s milk protein intolerance; watching him suffer, and knowing the cow’s milk-based formula was likely to blame was very difficult.  Stephanie felt as if her body had failed her baby, and every day, every supplemental feeding, the pain of this feeling was new.  “When I was pregnant again, I heard about mother-to-mother milk sharing on the IGT support page on Facebook and immediately knew this was what I wanted to do.”

Stephanie breastfeeding baby Elliot

The gift of donated milk fills more than the freezer, it fills the hearts of both the donor and recipient families.

During her pregnancy, Stephanie began visiting and posting her story to various mother-to-mother milksharing websites, such as Eats on Feets, Human Milk 4 Human Babies, and MilkShare.  She met profound empathy, generosity, and support in these online communities, and, over time, received donated milk from more than 10 mothers in 5 states – over 4000 ounces total.  Her first connection, however, was to a mother named Shelly.

Shelly lives an hour away from Stephanie, in southern Maine.  The first time she traveled to pick up the milk Shelly was donating to her and her baby, Elliot, Stephanie had to ask friends to loan her coolers – six of them – so they’d be able to keep all of the milk cold on the trip home.  “I couldn’t believe it!  Our 7 cubic-foot freezer was nearly full after that first donation!”  In her two trips to Shelly’s house, Stephanie acquired over 3000 ounces of milk.

The milk wasn’t all Shelly shared, however, and it wasn’t the only thing Stephanie and Elliot gained.  The two families became friendly, the dads enjoying each other’s company while the moms gathered Shelly’s milk and supervised their little ones, who, at the last pick-up, were delighted by an impromptu play-date.  “The connection was immediate, we clicked,” Stephanie says.  “It felt right.  The thought that a mother — and her child — would care so much as to aid us in our goals is truly heartwarming. The generosity that she has bestowed upon us leaves me in tears every time I think about it. We could never be grateful enough for the hearts of these mothers.”

Shelly with her children, left, with Stephanie and Elliot, right, at the last milk pick-up

For Stephanie, the ability to nourish Elliot on human milk alone meant a great deal to her, especially after her experience of watching Isaiah struggle with a substitute.  “No greater joy could I have than to know that, despite my severely low milk supply, my child is still able to exclusively receive the benefits of human milk. The healing that I have found with donor milk is more than I can put into words. The peace that Shelly, and all of the other wonderful donors, have given me is more than I could have ever imagined.”  Stephanie goes on to say that being able to fill an at-breast supplementer with “liquid love” (donor milk) and breastfeed Elliot, just like women without IGT do, has been life-changing for her.  “The healing I have found with this is incredible. IGT isn’t easy. There’s nothing easy about it. But what a blessing to have a nursing relationship in the first place, no matter how little I make! This has brought me so much peace.”  While her baby, now 16 months old, has weaned since about a month ago, Shelly continues to pump milk for Elliot, who is 7 months old now.  She shares in Stephanie’s desire to provide human milk through Elliot’s first year, and feels the joy of the impact she is making in Elliot’s life.

Even after that year goes by, Stephanie knows that Shelly and the other mothers who have assisted with her breastfeeding journey will hold a permanent place in her family’s heart.  She hopes her friendship with Shelly will be enduring as their children grow up and breastfeeding becomes a memory for both families.  Stephanie says “I will forever be indebted to Shelly and the other mothers who have donated their milk, time, and love.  Their giving hearts have changed my life. Shelly has helped us defy all odds. She is amazing and I am blessed having her in my life. I will never take for granted all that she has done for us. Calling her a milk donor will never be honorable enough … these moms are superheroes.”

If you have milk to donate, you have options.  Milk banks in the United States are always eager to accept milk donations, but certain requirements, such as the age of your baby, must be met.  Read more about donating to an HMBANA milk bank. 

If you’d like to share your milk with a mother and baby in need and you don’t meet the requirements for donation to a milk bank, or you would prefer a mother-to-mother arrangement, visit any of the milksharing websites that were linked above.  Be sure to adequately inform yourself and examine the risks and the benefits of feeding your baby donated human milk, and determine whether the benefits outweigh the risks for your situation and your baby.  

Posted by: Diana Cassar-Uhl, MPH, IBCLC | August 14, 2012

When the media spins the biological norm


I am often asked, through networks of professionals, to connect a reporter or media representative to breastfeeding mothers in a particular situation.  There are some requests that I scramble to satisfy, without reservation, because either the journalist is one whose work I am familiar with (and is truly supportive of breastfeeding), or because the population they are looking for is one that can benefit from exposure.  I’m all for raising awareness and bringing less-known breastfeeding topics into the cultural mainstream.

This week, however, a request began circulating that didn’t really pass my “sniff test.”  A newsmagazine-type TV show here in the United States put out a call for help with a story about breastfeeding, which would include information about New York City’s initiative to halt formula marketing on hospital mother-baby wards.  They sought mothers who have used or who have considered using pharmaceuticals, off-label (for a purpose other than what it was approved to treat), to stimulate milk production.  The title of the piece, along the lines of “Breastfeeding – Are We Going to Extremes?” got my antennae up immediately, and had the same effect on some of my colleagues.  The very title of this blog, normal, like breathing, speaks to this frustration, as I commented here … are we “extreme” when we get a cast to re-set a broken bone?  Is a kidney transplant “extreme” when someone’s kidneys don’t work?  Is an inhaler “extreme” when a person can’t breathe otherwise?  Why is a mother who takes measures to approximate, as closely as possible for her, the normal, physiological process of breastfeeding relegated into the “extreme” pile?

There are two populations who offer prime subjects for this request: adoptive mothers who wish to induce lactation and offer feedings at the breast, and mothers with chronic low milk production, such as those with hypoplasia/insufficient glandular tissue.  Given that I work closely with the latter population (which comprises a relatively small percentage of breastfeeding mothers), I was in a position to “recruit” mothers for this media piece.  My first concern was for the protection of these mothers.  One drug, called Domperidone (Motillium) was originally developed as an antiemetic/anti-nausea drug, but a side effect is … lactation! Domperidone works as a dopamine antagonist, and like for most endocrinological processes, blocking the action of a neurotransmitter sets off a domino effect – in this case, the result is sustained, increased levels of prolactin.  It seems easy enough:  some mothers need a little help making enough milk for their babies, Domperidone offers that help.  But!  Domperidone is not approved for sale or use in the United States and is currently under “orphan drug status” while researchers study how it works to support lactation, whether long-term use is without risk, and whether the high doses used to induce or support lactation are, indeed, safe for mothers and babies.  I did not feel comfortable sending a mother who is currently using Domperidone into the hands of a reporter who is attempting to determine whether she is “going to extremes.” A few of my colleagues and I were comfortable offering lots of expert voices, though – esteemed members of our field who could provide the facts about off-label pharmaceutical use for lactation support.  The producers were also directed to the Academy of Breastfeeding Medicine’s protocol on the use of galactagogues, which clearly states that these are last-resort measures to be called upon after all other possible causes for low milk production (breastfeeding management, anatomical issues in baby that preclude milk transfer, hormonal issues in mother that preclude milk production) are ruled out.  It is also important to recognize that IBCLCs cannot and do not act in a prescribing capacity, unless they are otherwise licensed or credentialed (MD, DO, RN, CNM, FNP, etc.) to do so.  While an IBCLC might provide information about Domperidone and other evidence-based measures of augmenting milk production to a mother who might benefit from them, she is NOT “prescribing” anything.

The producers of this show didn’t seem too interested in getting the facts, though.  One mother, who had successfully used Domperidone earlier in her breastfeeding (with insufficient glandular tissue) journey, felt safe sharing her experience. She spoke with a representative from the show and was told “we really want someone who is using it right now.” Hmm.  Another (media-savvy) mother shared her balanced, not-particularly-extreme experience of using Domperidone to support her breastfeeding experience, and was dismissed – asked instead, “Do you know anyone who has had a bad experience with it?”  Hmm again.  We offered to find a mother in Canada who is using Domperidone (there are no regulatory concerns in Canada or many other countries; Domperidone is prescribed by appropriately-licensed healthcare providers and used by mothers for lactation support), but the interest is in mothers in the United States.  You know, the ones who are “going to extremes to breastfeed.”

used with permission

Our collective radar piqued, we were especially interested in a blog post at the website “Moms Feeding Freedom” (punctuation theirs) that was published yesterday (August 13), because it contained many of the elements that were being proposed for this newsmagazine program’s piece. It is interesting to note, on the blog’s “about us” page, this statement: “MomsFeedingFreedom.com was made possible by a grant from the International Formula Council.” Needless to say, the blog post cites a “troubling trend” and describes mothers going to “extreme lengths” in order to breastfeed.  Hmm.

It is pretty obvious to me that this newsmagazine is NOT seeking to present a balanced look at mothers who work incredibly hard to provide human milk to their babies, rather, it is seeking to produce, in made-for-TV form, a sensationalized, flame-fanning piece that echoes the blog post on “Moms Feeding Freedom”.

Some of these mothers turn to herbal and pharmacological galactagogues to boost their own milk production, others need to supplement so their babies can grow.  What goes in the supplementer?  Well, there are some who think that’s an issue of “extremes,” too, but fortunately, the cultural opposition to human milk for human babies, either milk collected by milk banks and dispensed by prescription to babies in need, or milk acquired by mother-to-mother milk sharing, is dwindling fast.  Of course, there are mothers who, upon learning their own bodies won’t be able to completely nourish their babies, choose to supplement whatever breastfeeding they can do with artificial baby milk – and there are others who decide they just plain don’t want to or can’t breastfeed at all, so they switch immediately to bottle-feeding without looking back.  These mothers aren’t any less loving, intelligent, or devoted to their babies than the ones who do seek to make breastfeeding work.  The very existence of mothers who prioritize breastfeeding as part of their mothering experience does not lessen or cheapen the choice of mothers who opt not to.

used with permission

I am publishing this blog post to raise awareness of the measures the media (perhaps funded by WHO Code-violating sponsors?) will take to marginalize mothers who go the extra mile to breastfeed their babies.  These mothers have, frankly, been through enough upon discovery that their bodies don’t do what they expected them to do; and the availability of assistance to preserve a breastfeeding relationship does not discredit mothers who choose not to take advantage of that assistance, rather, it allows for true freedom of informed choice for all mothers.  I have worked with countless mothers who did not produce all the milk their babies needed, but who valued what milk they could offer, or rejoiced in the ability to feed their babies at their breasts rather than by bottle.  These are mothers for whom breastfeeding was so much a part of what they anticipated about mothering, mothers who learned to accept their limitations and work with them to whatever capacity they wanted or could.  Mothering success is not measured in ounces – or drops – of milk that flow from breast to mouth, it’s measured in the love that flows between a mother and her baby.  For some mothers, embracing, as far as is possible, the biological norm for infant feeding and nurturing is what comes most easily – the oxytocin and prolactin bursts that accompany feeding at the breast and the triumph over obstacles that others may consider insurmountable offer more than adequate compensation to the family that goes the extra mile to breastfeed in the face of difficulties.

Shame on anyone who seeks to malign or marginalize these brave, devoted mothers.  They’re not “going to extremes,” they’re taking reasonable measures to make a normal process work.

For more images of mothers and babies who have overcome obstacles to make breastfeeding work for them, see this beautiful YouTube video by Melissa, a mother with hypoplasia/IGT.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | August 8, 2012

The surgeon who changed my life


Well, no, it’s not really like that.  I wasn’t sick, and the “changing” part was that the guy refused to operate on me.  At the time, I was kind of mad about it.

I was 26, and in the best shape of my life having just run my first marathon. I loved running and spent a lot of time in the gym, too.  At my well-woman check-up, the Nurse Practitioner took one look at my chest – the entire perimeter of my body where my sports bras touched me was chafed and oozing.  Shoulders, underarms, all around my ribcage were just wrecked.  Even at 125 pounds (ah, youth!), my breasts were still an ample 34DD, and I struggled with back/neck/shoulder pain, deep grooves in my shoulders, and chafing was part of my existence.

On the beach, weeks after meeting with that surgeon

“Why on earth have you not had those things reduced?” she asked me during my breast exam, obviously disgusted by the scabs and glossy, exposed skin. (I feel compelled to mention that this woman is still practicing around here, and I’m told she still says such horrific things, but at that time, I was just happy to have a civilian female as my primary care provider.)  Honestly, it hadn’t really occurred to me that I would be a candidate for a breast reduction, other than that I wished I could wear cute, sleeveless dresses or tank tops that showed off my fit arms.  Surgery hadn’t seemed feasible until then.

“Um, I don’t know?” I answered, feebly.  She put in a referral for me to see a surgeon, which immediately led to another referral to the plastic surgery clinic at Walter Reed Army Medical Center.  The year was 1999.  I was sent on medical TDY from New York to Washington, via the Delta Shuttle out of LaGuardia with a bunch of businessmen.  I don’t remember much about getting to Walter Reed from the airport, except that it was scary.  The hospital was old and tired.  I found the plastic surgery clinic and sheepishly presented myself for my appointment.

I don’t remember the doctor’s name.  I remember that he was from North Carolina, and his accent was pretty thick.  I remember that he drew with black marker on my breasts and chest, and took pictures and notes, and didn’t say a whole lot while he was doing that.   There were Xs and lines and circles and arrows all over my upper body.  I remember that I felt really weird sitting there in a medical setting, with my visions of sleeveless dresses but knowing this was more about finding a solution for my chronic shoulder pain and the awful chafing.  And I remember what he said when he finally spoke to me after his assessment.

“Have you had any babies?” he asked me.

“Um, no.  I don’t even have a boyfriend right now.”

“So you think you might have babies someday?” he went on.  Why does this matter?  Do I get my breast reduction or not?

“I don’t really know … probably.  Yeah, I hope I have babies someday.”

“Look,” he spoke quickly, but with his North Carolina twang.  “When you get pregnant, your breasts are going to go south.  They all do, from the pregnancy.  So do me a favor – have your babies, and breastfeed them if you want to.  Then, when you’re all done, and your breasts have gone south, come back and see me, and I’ll make you the envy of all your friends, because you’re actually a candidate for a breast reduction, but they won’t be.  Come back when you’re done using your breasts.”

I was shocked, and a little embarrassed.  I had only ever seen one baby breastfeeding up close, and breastfeeding was the last thing on my mind at that point in my life.  I think my disappointment showed on my face, and the surgeon spoke again.

“I’ve done 687 breast reductions in my career, and only two have been on women who weren’t done having babies yet.”  He went on to tell me about those girls – one, a teen with such severely large breasts, she needed to secure herself with duct tape just to get out to the door to school.  “She would have been an L-cup,” he told me.  I don’t remember what he said about the second case because I was lost in thought about how this guy probably changed that poor young girl’s life … for the better … but it had become clear he wasn’t planning to change mine, at least in the way I was seeking.

I left the clinic and rode the Delta Shuttle with the businessmen back to LaGuardia airport, sad to deliver the news to my friends that I wasn’t going to have a breast reduction after all, and I wouldn’t get to wear cute tops and dresses, and I’d still be sore and chafed.

Because the surgeon wanted to make sure I had the opportunity to breastfeed someday.

Now, there are women who have breast reductions and go on to breastfeed.  My friend and colleague Diana West, IBCLC wrote about them in her book Defining Your Own Success: Breastfeeding After Breast Reduction Surgery and has been educating women and healthcare providers about breastfeeding after surgery for over a decade.  I didn’t know about these women in 1999.  I didn’t really care in 1999.

She was about 4 months old here — so sweet.

In December of 2002, I gave birth to my first baby.  I had read books and prepared to breastfeed her, but it wasn’t until we had major problems doing so that my commitment to nursing Anna was solidified (yeah, I’m one of those people who likes to do things that someone tells me I can’t do, so on our 5th day in the hospital, when that nurse said “you can always just pump and bottle-feed,” it was game on and there was no flat or inverted nipple, no bilirubin of 22, no return to work, no nothing that was going to keep me from breastfeeding).  I stayed committed through 105 fever and severe mastitis on my 8th day (while my husband was gone the entire day and night playing a gig with Tommy Tune in NYC); I stayed committed through Anna’s bloody diapers and bad, bad guidance from our pediatrician; I stayed committed at 3 weeks when Anna refused to sleep for more than 45 minutes at a time, happy only when I nursed her, as I hissed to her half-sleeping daddy at 2 in the morning, “I know why people quit this.”

At some point, the dust settled.  Maybe it wasn’t even until after my second baby was born – I honestly don’t remember when it happened for me, that feeling of empowerment, of knowing that I was doing something for my baby that countless women before me had done for theirs, something only I could do for mine.  I discovered somewhere along the way that breastfeeding wasn’t only about what I fed my baby, but about how I mothered her and how she learned to relate to me.  The God-given potential of my big, unwieldy breasts – even bigger and more unwieldy now after three pregnancies and nearly a decade of lactation had been fulfilled.

She was always happy there … I was home base.

I don’t know the name of that North Carolina plastic surgeon who worked at Walter Reed Army Medical Center in the summer of 1999, but there isn’t a single day that I don’t think about him with a thankful heart.  The experience of breastfeeding has been a life-defining one for me, leading, of course, to my becoming a La Leche League Leader, an IBCLC, and now working toward a Master’s Degree in Public Health.  I aspire to study epidemiology next, and to spend the rest of my working life conducting and publishing research about breastfeeding, with the hope that my life’s work can enable more mothers to be empowered by their experience of breastfeeding.  If you had told me in 1999 that breastfeeding, mothering, epidemiology – any of this – would be my sweet spot, my calling, I would have laughed at you.

Would I have breastfed my own children after reduction surgery?  Possibly, but given the woefully substandard breastfeeding support where I received my medical care and the fact that no women in my family had positive breastfeeding stories to share, I don’t know what lengths I might have gone to in order to make it work if the obstacles had been any bigger than the ones I faced.

Today, I am 39, with a strong enough history of breast cancer to spur some healthcare providers to talk to me about a prophylactic double-mastectomy and breast reconstruction.  If determined beneficial by genetic tests for BRCA1 and BRCA2, I could, perhaps, be a candidate for a surgery that could prevent cancer and give me the chance to go sleeveless at long last.  Now, though, I’m ambivalent.  I struggle with whether I could really part with this assemblage of glandular and fatty tissue that has played such a significant role in the lives of my children and me.  What if I ever needed to lactate for a grandbaby — or if one of my children grew up and got sick, and I could help by re-lactating and providing human milk again?  Such considerations don’t occur to most people, for whom breastfeeding is a small part of their history, but for me, they are huge.

My answers will come, or perhaps the big decisions will be made outside of my control — like the 1999 decision of an Army plastic surgeon that changed my life.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | June 15, 2012

Understanding oversupply


Oversupply, forceful let-down, foremilk/hindmilk imbalance … all of these strike fear in the heart of new mothers because they translate to an inconsolable, visibly uncomfortable, crying baby.  He may want to nurse all the time, because the sucking behavior soothes him when his tummy hurts, but the more he nurses, the more miserable he becomes.  There may be blood in his diapers, maybe he chokes when he starts breastfeeding, or he spits up a lot after every feeding.  You’re desperate for a solution that won’t threaten your milk production, because you really want to continue breastfeeding your baby – but your baby doesn’t seem to “like breastfeeding” and you’re feeling rejected and discouraged.  What causes this constellation of circumstances?  There is a lot of information out there about oversupply, overactive milk-ejection reflex (OAMER), and what has been called foremilk/hindmilk imbalance. I will do my best to help you understand WHY your breasts are so eager, WHY this is so irritating to your sweet baby, and offer you some resources for how to find the solution that works for you and your baby.

First, it is very important that you ensure your breastfeeding management is optimal and you are “watching baby, not the clock.”  Some mothers unintentionally create an overproduction of breastmilk when they, perhaps out of concern that they’ll make enough milk, or maybe to make bottles so grandma and daddy can feed the baby, pump or express more milk than their babies are actually taking.  Most mothers, if feeding on demand and not by a schedule, and not over-stimulating milk production, will make the milk their babies need.  Hormonal imbalances are another reason for overproduction of milk; if you have a history of PCOS, you may be susceptible to oversupply.  Postpartum thyroid issues can also have an effect on milk production.  Be sure to rule out medical causes of hyperlactation first.

You may have been told that your baby is fussy, has a skin rash, is gassy, spits up, has diaper rash, a red ring around his anus, or green poop because of something you’re eating, oversupply, or foremilk/hindmilk imbalance.  You may also be hearing that “gassy foods make gassy babies” when you’re breastfeeding, and you’re confused and concerned that you will have to somehow satisfy your ravenous appetite on salad and air.

A note about how you make milk:  your milk is synthesized from ingredients in your bloodstream, not in your digestive tract.  Gassy baby after that stir-fry?  It probably wasn’t the broccoli …  yet, you’ve read something or someone has told you that eliminating certain foods from your diet may be the answer to your crying, uncomfortable baby.  How can this be possible?

A healthy, mature digestive tract (or “gut”) is “sealed;” nutrients are absorbed and wastes are contained until they are eliminated.  This “sealing” takes place in a healthy, breastfed baby sometime around the middle of the first year (immunoglobulin from your milk helps to coat your baby’s small intestine in the meantime), which is why it is advised that we hold off on introducing solid foods until then; also, the first foods we introduce are hopefully less likely to be allergenic and irritating to your baby’s gut.  This is where the claims that breastfeeding protects babies from allergies and eczema come from, IF our own (maternal) gut is healthy.

For many of us, though, our gut is not healthy and sealed, and is known as a “leaky gut.”  Perhaps we were formula fed as babies, or we’ve been on antibiotics; maybe we have a food allergy or intolerance we don’t know about, or our diets are full of processed, irritating ingredients we’ve been led to believe are “foods” because we can buy them in the grocery store … whatever the reason, our bodies mistakenly allow proteins from foods we eat to pass into the bloodstream, where they can then pass into your milk.  So, if your gut is leaky or less healthy than ideal, irritating proteins are passing into your milk and being fed to your baby, creating many of the same symptoms commonly seen in babies fed cow’s milk or soy preparations: eczema, gas, diaper rashes, and later, reactions or sensitivity to allergenic foods.

A Google search or a Facebook page may tell you your baby’s problems are caused by foremilk/hindmilk imbalance.  This was once a commonly accepted explanation and “block feeding” (offering the same breast at every feed for a prescribed number of hours, then offering the other breast for the same number of hours, regardless of how many times the baby wants to feed in that time) was the preferred method for dialing down milk production and encouraging the baby to consume the fatty, satisfying “hindmilk.”  Now, however, the idea that a mother makes two different kinds of milk is being challenged and the practice of block nursing doesn’t seem so vital.  Nancy Mohrbacher, IBCLC, FILCA published this blog post on the foremilk/hindmilk misconception and what current research tells us.

Today, we are also thankful that the Academy of Breastfeeding Medicine Clinical Protocol #24 is available to us: Allergic Proctocolitis in the Exclusively Breastfed Infant.

From this, we learn that an exclusively breastfed baby can experience allergic symptoms as a result of maternal intake.  Cow’s milk is the primary offender cited, and this is consistent with my clinical experience.  All of the mothers I have worked with who had symptomatic babies reported some, if not complete, improvement after eliminating dairy products from their diet.  Other mothers needed to eliminate soy, eggs, and/or gluten to bring their babies to complete relief.  Some very detailed analyses of gut health, with some commentary on breastfeeding mothers and babies, can be found at this link.

Does this even relate to oversupply?  If so, how?  It’s clear that the symptoms in babies are similar.  Some professionals suspect a cause and effect relationship, that something about the mother’s gut health causes both oversupply AND allergic sensitivity in the breastfed baby.  There is no current, specific research linking maternal gut health to oversupply, but it has been my experience that most mothers with oversupply also have babies with allergic reactions to something in their milk. (Tongue tie in the baby is also very often present, but this goes beyond the scope of this post.) To me, this suggests that the mother’s digestive issues (which she may or may not be aware of – she may feel perfectly healthy and well), can result in a host of abnormal outcomes, among them oversupply and forceful let-down.  While not “evidence-based practice,” rather, “practice-based evidence,” I’ve noticed over the last 7 years that the mothers who eliminated one or more allergens from their diets were delighted not only with their happier babies and normalized milk production, but with how terrific they felt without the allergen!  Caring for a newborn and feeling terrific!  Years later, many of these mothers tell me they never went back to the offending ingredient, or introduced it in far reduced amounts once their babies got older and/or weaned.

Do you see yourself and your baby in this post, but feel discouraged because you just went through a pregnancy where you couldn’t drink alcohol or caffeine, eat sushi, soft cheeses, or deli sandwiches, or enjoy a medium rare steak?  It may feel unfair that now, you need to give up ice cream, cereal with milk, and your favorite candy bar (read the label, it has soy in it!).  Don’t worry!  There are so many wonderful foods you can eat!  I’ve written on my blog about delicious, wholesome, healthful, real foods that won’t make your baby cry in pain.

Of course, you may choose to try other measures to resolve oversupply before changing your diet.  If you’ve already ruled out possible medical reasons for hyperlactation, changing your breastfeeding position to one that makes the milk flow against gravity is one (side-lying and “laid-back” are two options) measure that is gaining popularity.  “Block feeding” is still commonly recommended, but some IBCLC’s report that the method is either incorrectly communicated or not well understood, and mothers can jeopardize their milk production capability if they are not closely monitored during the block feeding period.   If your IBCLC suggests block nursing, be sure to ask her to be specific about how long each block should be, and for how long you should continue the regimen.  Antihistamines, sage, and mint (for example, tea made from steeping fresh mint leaves) are also ways to reduce milk production.  These methods, however successful they may be, represent a resolution of the symptoms, not of the cause, therefore, even if the oversupply is corrected, sensitivities may still persist in your baby.

Breastfeeding your baby can be a pleasurable, memorable experience, definitely worthy of any adjustments you may make to ensure your baby’s health and comfort.  The best news:  there are resources for you, and you will find solutions that work for you and your baby.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | May 31, 2012

I breastfed in uniform


I didn’t think I was going to jump into this conversation, because I sometimes feel like my 17-year military career has been atypical enough that I shouldn’t bother telling people I’ve served.  I used to be in the Army.  I spent my entire career as a clarinet player (among other things, but that was my main job) in a Special Band.  I won my job as I was finishing my undergraduate degree in clarinet performance, and it was a great gig.

My official photo in 2000, before marriage or children (closely cropped because I’m not savvy enough to edit the text in the top left).

The media hubbub about the photo of the two Air Force mothers breastfeeding their babies … you know what I’m talking about.  One’s nursing twin girls and the other’s got a toddler across her lap.  It’s a gorgeous photo, but, like the now-infamous TIME cover that not-so-accurately portrayed a breastfeeding 3-year old, it isn’t really a good illustration of what “breastfeeding in uniform” actually looks like.  A lovely image of the mothers who were part of a photo shoot, sure, but not what we should be basing our judgements on about the behavior in general!  My friend Robin Roche-Paull, author of Breastfeeding in Combat Boots, shared it with her community of followers, and over the Memorial Day weekend, it went viral.

Of course, it was a conversation-starter, and that meant people publicly proclaimed the aspects of that photo that made them uncomfortable.  I confess, my very initial reaction upon seeing it was a slightly uncomfortable “whoa,” which I’ll explain in a minute.

I breastfed my children for more than half of my Army career – many of my own stories are represented on this blog.  Yet, for all those years breastfeeding, I have NO pictures of me doing it in uniform.  Not a single one.  In fact, I don’t have any photos of me in uniform with my children.

At the Mormon Tabernacle — my 7-month old baby was in her daddy’s arms just offstage.

I breastfed in every uniform I ever had to wear.  Untucking the t-shirt from the shorts on the APFU, unbuttoning the bottom of the weskit shirt in Class B’s, unzipping my high-collar concert coat (under which was a a cami or tee) to soothe a fussy baby on the hallway floor of a high school during a long concert’s intermission.  ACU’s were harder to get back together than other uniforms after breastfeeding or pumping, but I did what I had to do.

The Sierra uniform was the worst – that was my summer concert uniform.  My babies loved to grab at the ribbons and insignia while they breastfed, sometimes hard enough to dislodge a “dammit” backing, forcing me to scramble to either find a spare or maybe a folded up piece of cardboard so my ribbon would sit straight during the concert and not stab me.  It was easy enough to leave the stiff white shirt tucked into the who-thought-this-fabric-was-good-for-a-summer-short-skirt and unbutton a few of the bottom buttons to breastfeed discreetly, but in 94-degree heat, feeling like my pantyhose were melting onto my legs and desperately hoping my 6-month old fussy baby would settle enough to nurse before I had to take the stage, I was more worried about the position of my legs so I wasn’t flashing my underwear at the people setting up their lawn chairs and blankets for the concert that was going to start in … how many minutes do I have?  Come ON, baby, this is your last chance and there’s nowhere for you and your caregiver to go to escape this heat, unless you want to go to the car and turn on the air conditioner?  Who has the car keys?  (My husband is still in the unit I’m leaving.  This was all a family endeavor.)  He has the keys?  He’s already on stage?  Aaagh …

Sharing a solo feature — our two (at the time) children listened from the audience.

And it dawns on me, why I have no photos of me in uniform with my children.  I was already juggling so much– making sure our caregiver went to the bathroom before the concert started, were there enough diapers and snacks in the bag?  Are the people seated near my three young children planning to smoke during the concert?  Will our NCOIC try again to tell us we “shouldn’t” have our children at our concerts (but the ill-behaved brats that are running, yelling, and playing with a beach ball over there, next to the stage are of no concern)?  Will the fireworks make my babies cry?  Will the music be too loud?  Will their happy dancing irritate the concertgoers around them?

And, oh yeah.  I’m about to take the stage now and perform an eclectic program of challenging music with the highest level of musicianship my years of study have prepared me for, while smiling and looking the part of the military ambassador to our public that I am.  Was.

“So don’t bring your kids with you,” people would say (behind my back, rarely to my face).  Maybe that’s possible for some, but a 2-hour concert often meant a 9-hour workday, usually on a weekend or holiday, and my babies didn’t take bottles.  Could I have “forced them to” like some people suggested, leaving a caregiver stuck in my house with a screaming, inconsolable baby when the alternative is to enjoy a concert with a satisfied, happy baby who sees his mother right there on stage?

Sometimes, they would fall asleep before the concert ended.

I don’t want photos of myself breastfeeding in uniform.  I don’t want to remember planning my pregnancies around our busy seasons so that long, unavoidable separations would happen when my babies could handle them better.  I don’t want a scrapbook page of pumping at first aid stations (or being turned away from them and forced to find a less suitable place); of finding dead bugs belly-up in a Montana hotel with 2 children and an au pair in tow; of appointments with the Staff Judge Advocate to have my rights explained to me because someone in my chain of command wanted to call our overnight trips “deployments” when they were actually “temporary duty” (TDY) and governed by a different set of expectations; of the ignoramus outside my locker room door asking how long I’m going to be pumping on our 20-minute break because he had to ask me a question (that was just as easily asked when rehearsal ended or before it started).

I know how fortunate I am that I never had to separate from my children for weeks or months at a time; that I never had to go into harm’s way; that what I went through to provide my milk to my babies was mundane compared to what so many mothers surmount; that my children had some really positive experiences because their parents were professional musicians and professional Soldiers.  (How many 4-year olds do you know that snap to their feet and put their hand over their hearts when the National Anthem starts?  Do they know the words?)

My two older children, left and right, with their best friend (and daughter of their caregiver for the evening, center) — having fun before the concert started!

I did have to work in a male-dominated environment, complete with the jokes and childish behavior that accompanies breastfeeding and pumping at work (until they started getting married and having babies who needed help breastfeeding).  Motherhood – heck, parenthood – is seen as a liability, not only where I worked, but throughout our culture.  Breastfeeding is seen as a choice a military mother makes – but if she makes it, she’s perceived as not putting the mission first (whether or not that’s actually true), and in a culture that values the mission above all else, even the most outstanding contributor will find herself cast out.

I want to forget all of it.

My “whoa” reaction to the photo-gone-viral:  the women are outside in utility uniforms with no headgear.  If discretion was desired, the mom of twins could have adjusted her uniform to provide it.  If (heaven forbid) this photo is to drive policy, it can hurt the future for women in uniform, and I say again – this is NOT how breastfeeding in uniform really looks — at least it didn’t for me or the breastfeeding Soldiers I worked with.

When we expect/direct a sector of our population to “cover up” or somehow hide that they nurture their babies in accordance with the biological norm, we are not making a statement about that sector of the population — we’re making a statement about the biologically normal behavior.  Teachers are professionals, too. Should they not breastfeed in their teaching clothes? What about chefs? Or dentists? Is it OK for a discount store employee to nurse her visiting baby in her smock? What about a nurse in her scrubs, picking up her baby from daycare after a 12-hour shift?  Are they disgracing their respective professions?  Perhaps the public’s “whoa” reaction relates to this question:  are we still, as a culture, trying to deny that femininity — BEING FEMALE — exists in and augments our military?  Does seeing a breastfeeding mother in a uniform rouse something in you that you can’t reconcile with your ingrained beliefs?

Posted by: Diana Cassar-Uhl, MPH, IBCLC | May 25, 2012

Forgiving ourselves and the truth about breastfeeding


I haven’t met a single person who enjoys “the mommy wars.”  I’d go so far to say I even despise the WORDS describing this us vs. them concept that has permeated our culture.  Let me cut to the chase:  mothers who parent differently from me are not my problem.  The culture that makes the biological norm seem like the more difficult, less convenient, unrealistic, extreme choice is my problem.  Cultural constructs, ranging from an uninformed father to the deeply-rooted misogyny of a supervisor in the workplace that make  the biological norm NOT the best choice, are my problem.

There are far too many of these constructs, and as long as there is money to be made for every mother who does not breastfeed, the fight to eliminate those barriers to the biological norm will be a messy one … especially if we burn half our ammunition fighting against each other.

I’ve been reading and listening to a lot of Brene Brown.  She’s a psychologist who has spent several years researching, essentially, what distinguishes people who live connected, loving lives from those who don’t.  She finds that vulnerability, allowing oneself to be seen, is one key to experiencing what she describes as “wholeheartedness,” and that shame is the ingredient that prevents vulnerablity/wholeheartedness/authenticity. She says that love and belonging are available to those who believe they’re worthy of love and belonging. (I can’t even begin to summarize the significance of her work in one paragraph, so I urge you to take 25 minutes today and 25 minutes tomorrow and listen to these two TED talks by Brene Brown … they’ve changed how I look at everything.)  The Power of Vulnerability     Listening to Shame

What is most fascinating to me about what Brene Brown has uncovered is that, when we aren’t wholehearted and authentic, when we’re failing to confront our shame, we become toxic.  Cutting down others who make different choices from our own is toxic.  Being unable to see our own shortcomings is toxic.  Believing we are only “enough” if we can check all the boxes and be someone else’s definition of perfect is toxic.

I started my blog with the goal of normalizing breastfeeding in American cultureI defined normal, and contrasted it against the alternatives.  I also acknowledged that, even in the absence of barriers, some can’t and some don’t want to.  In our culture, the alternative has become preferable to the norm — bottle-feeding is the cultural norm.  Thanks to the information age, we are at no loss for the latest research, opinion piece, or controversy, whether from the comfort of our homes, on the go with our smartphones, or wherever we are.  The myths and misinformation get dressed up as studies or passed along as fact by the self-appointed authority of the day.

“Pacifiers won’t interfere with breastfeeding.”

“Breastfeeding mothers don’t contribute to society.”

“Breastfeeding an older child makes him dependent.”

“Sleeping with your baby is dangerous.”

“It’s unrealistic to expect today’s mothers to breastfeed exclusively for 6 months.”

It can all get deafening in a hurry, leaving us insecure, defensive, and ready to attack anyone who challenges the decisions we finally come to in all the noise, because we’ve embraced cultural norms that are at odds with our biological norms.

The mother with insufficient glandular tissue whose breasts didn’t develop enough for her to exclusively feed her baby isn’t going to let him starve because supplementation isn’t biologically normal.

The mother who carries the health insurance for her family isn’t going to quit her job because feeding expressed breastmilk by bottle isn’t biologically normal.

The mother who quit breastfeeding her twins before they were two weeks old because no one in her immediate support network thought breastfeeding was important or necessary (because they hadn’t breastfed any of their babies, either) isn’t supposed to berate herself for the rest of her babies’ first year because she’s buying, mixing, and feeding an alternative to the biological norm.

Yet, rather than taking a deep breath and acknowledging that we did the best we could with the choices we believed we had under the circumstances we faced, we struggle with whether we’ve done enough – and frankly, the notion that we’ve done anything less than 100% for our children is just too painful to bear.  The shame that we might not have “done enough” takes our breath away.  We sweep it under the carpet, or more likely, we undermine those who somehow accomplished what we felt to be impossible – we scoff at “supermom” and imagine she’s the unattainable ideal, or we consider her choices not worth it – knowing nothing about her story or what drove her decisions.  There are winners and there are losers.  There are haves and have-nots.

I’d like to think there’s another way, and it starts with first accepting that we do the best we can in the situations we’re in, and forgiving ourselves when a booby trap (thanks, Best for Babes) interferes with our efforts to breastfeed.

But, in our noble efforts ensure that no mother feels like she hasn’t done enough, we are making a grave mistake.  We tiptoe around the importance of the biological norm in birth, infant feeding, and care.  We say “breastfeeding is a personal choice,” but do we spend enough energy understanding why the alternative is attractive?  Instead of saying “my kid is healthy, so don’t try to make me feel guilty,” why can’t we say “I chose an alternative, but I did so after weighing the risks and the benefits to my family?”

When we are dismissive of breastfeeding as the biological norm, touting it as a “lifestyle choice,” that mother with the hypoplastic breasts won’t feel like demanding a full explanation of her condition from her healthcare provider and pressing for research into the environmental exposures that might have caused or worsened her lactation failure.  That mother in the workplace feels no reason to find ways to be with her baby AND fulfill her job responsibilities, or put pressure on the culture so that her motherhood is respected, not viewed as a liability.  That mother of twins might not seek to learn to bottle-feed her babies in a manner that preserves what she can of the biological norm, such as is highlighted in this article by Analytical Armadillo, or explore why breastfeeding isn’t part of her culture, why it isn’t considered part of the normal, regular progression of pregnancy and mothering.

By accepting breastfeeding as a lifestyle choice in an effort to not make each other feel bad, we cheapen the importance of breastfeeding as a public health issue.

We permit poor or no maternity policy when a working woman gives birth.

We expect flight attendants and wait staff to ask that woman feeding her baby to cover up.  We expect breastfeeding mothers to stay at home or pump and feed a bottle if they dare leave the house.

We allow supervisors to discriminate against breastfeeding mothers who require time and space to pump during their workday or who keep their babies with them whenever it’s practical – because breastfeeding mothers “made a choice” that is perceived as negatively impacting the workplace (regardless of their contributions).

But if we can embrace how we’ve fallen short, and instead of attacking each other, put pressure on the culture that has done little to uphold the biological norm, that is where progress happens.

Let’s acknowledge that after we give birth, our bodies make milk for a reason … and let’s press the culture for the option to do better.  Then, and only then, will “choice” truly be a factor in infant feeding – informed choice that exposes all of the biological AND cultural risks and expenses of each option, and forces progress toward eliminating all of the barriers to giving our babies everything they deserve.

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