I took a breastfeeding class last week.  Yes, I actually took a class. And I’ll be attending it again this coming week as well.  This from a midwife, someone who has taught countless other women about breastfeeding, and who has helped countless women get a good latch with their brand new baby.  But there’s a big difference between helping a newborn (as in, minutes-old) baby latch for the very first time versus addressing the myriad difficulties and complications which come up over the course of time: the engorgement, the first growth spurt, and then what happens after the first growth spurt.  There’s much to be said for getting a baby onto the breast in the first hour of life, but as a midwife you’re not doing much lactation support at 3 weeks of life.  Maybe a bit more at the 6 week postpartum check-up, but in between birth and 6 weeks, a lot of breastfeeding happens, and a lot of challenges arise.

Case in point: for me, my challenge is oversupply.  I have a huge oversupply problem!  Who would have guessed that I would be such a milk goddess??  Whenever I thought about potential breastfeeding snafus, I always thought about undersupply.  It didn’t even really occur to me that oversupply could be a problem.  But it can indeed  be a problem.  A very challenging problem, in fact.  So, I will speak to this for a bit, since I now have first-hand experience with it (and maybe someone else wants to write a guest article about first-hand experience with an undersupply problem?).

This is what oversupply looks like: ever since my son’s growth spurt, my breasts have been painfully full.  When he tries to latch, he has a hard time getting his little mouth to even indent the breast, and then when he does, the milk flows down so quickly it completely overwhelms him, and he ends up pulling back and choking.  This has made his latch very painful for the past few weeks.  In an attempt to stem the overwhelming tide of milk, he’s been pursing his lips and using a much smaller latch than he was the first two weeks, which has led to him sucking little grooves into my nipple and turning the nipples black and blue.  I keep trying to get him to use a wider latch, but inevitably he closes his mouth to a smaller diameter again, and I can’t really blame him.  I would do the same, too, if the milk was flowing so quickly into my poor mouth.  During let-down, my let-down has been so forceful that I have actually sprayed him in the face with milk, like a shooting milk geyser!  Poor guy, how is he supposed to drink from a breast that is out to get him like this?  Every feeding has become a wet and sticky mess.  By the end of it, I’m covered in milk, he’s covered in milk (bring on the baby acne!) and my clothes are covered in milk.  Forget trying to nurse in public at this point, there is no way we can be discreet at this point.  Every feeding feels like a pitched battle against the exploding milk fountain of doom!

Then, there are the digestion issues.  Because the milk is flowing so fast, he ends up gulping a lot of air.  Despite frequent burp sessions, his little belly is full of air by the end of the feeding.  He’s also become a really fast drinker to try to cope with the let-down.  He may finish the breast in about 10 minutes, but it hasn’t satisfied his urge to suck yet, so he continues to try to suckle at the breast for another 20 minutes or so.  And because he’s drinking so quickly, and filling up so quickly, he’s not always getting to the hind-milk at the back of the breast, which comes at the very end of the feeding.  I just found out that hind-milk is crucial to improving his digestion.  If he’s getting enough hind-milk, he digests everything more slowly, and the poop is mustard yellow and much easier on his G.I. tract (less gas, less explosive poops, less fussing).  If he’s not getting enough hind-milk, everything digests much too quickly, with a lot more gas and fussing involved, and comes out green instead of yellow.

I went to a breastfeeding class last week, and this is the advice I was given: first, try more upright feeding positions, where he’s sitting up or across my chest but I am leaning back so that his head is over the breast, rather than under it.  This will make the milk have to work against gravity, which might help slow the flow down.  I was pumping a little bit before feeding him to try to soften the breast somewhat and make it easier for him to latch.  The lactation consultant advised to stop pumping immediately, because this was just encouraging more milk production!  Instead, I can manually express just a bit, if I have to, but if at all possible I should just let him eat directly from the breast, and supposedly that will help regulate our supply/ demand more quickly.  She advised I continue with the frequent burpings, and that if he finishes the breast quickly but still wants to suck, I can offer him a pacifier or clean finger to suck on instead, since continued sucking helps with his peristalsis and may also help him digest the milk more easily and spit-up less.  She suggested that I could also try block feedings if I wanted to in an effort to make sure he gets enough hind-milk (this is where I offer him the same breast for 2—or more—feedings in a row, so that I know for sure that the breast is completely drained and that he got the hind-milk before moving on to the other breast).  However, other advice is suggesting that maybe block feedings are not the best idea, since this increases the risk of mastitis and may eventually lead to undersupply (see the link below from Nurtured Child).

I’ve been looking up some other resources about oversupply on the web.  This is what I’ve found so far, which has been very helpful:

Kellymom.com – great resource for all things Breastfeeding.  I just added it as a permanent link under the Breastfeeding section.

Nurtured Child: Managing Oversupply (written by a LLL leader), which discusses frequent switching of sides rather than block-feeding as a way of dealing with it.

At the moment, we’re skipping the block feedings, I’m doing manual expression when needed, and just letting the little guy eat directly from the breast when he’s hungry.  And hoping that the supply/ demand issues will sort themselves out soon.  But no, it’s not easy.  Even with too much milk, there are still challenges.  I will keep you all posted!

While Facebook maintains that breastfeeding photos are okay, it does have a no-nipple no-areola policy, and will remove photos that other users indicate as obscene, which is apparently what happened with the breastfeeding photos that were originally removed.  I still don’t understand how photos of teenagers clad in lingerie are acceptable while photos of breastfeeding babies are not.  While some people argue that this is for the protection of the women and babies from predators, I really think what it does is send the message that public breastfeeding is not acceptable.  It seems like any use of the breast for anything other than sexual gratification is what’s considered obscene.  In our sex-drenched culture, sexy women in lingerie won’t even make us bat an eyelash, but a baby taking sustenance from a breast….that’s obscene.  How can breastfeeding not be considered “family-friendly”?  It’s the very essence of family friendly — it’s feeding and nourishing said family.  And for the folks who wonder why people would want to even take a photo of a nursing baby in the first place…just look at all the photos taken of babies with bottles in their mouths.  It’s cute, and as a parent, I can only imagine that there’s something very satisfying and fulfilling about watching your baby eat.  Babies are born to breastfeed, and it’s not obscene.  Anyway, kudos to the lactivists of California for making their real world presence felt outside the Facebook headquarters this holiday season.

And with that, I’m off for the rest of the year.  See you next year!

First, Verizon Wireless, the cellphone megagiant, has gotten itself into a heap of trouble by initially refusing to allow NARAL Pro-Choice America to host a text messaging service on its network. Verizon initially claimedthat company policy allows it to refuse “highly controversial” and potentially “unsavory” messages from being distributed on its network. NARAL quickly shot back with an action alert and Verizon was flooded with thousands of e-mails and text messages from angry subscribers, and several anti-censorship groups also joined the fray. Quickly realizing it had made a huge mistake (especially when it discovered that other cellphone networks like Sprint and AT&T had approved the NARAL text messaging service without a whiff of protest), Verizon reversed its position, allowing the NARAL text service to go forward, and issued a statement in the press, but NARAL is still hounding Verizon to put its new public policy in writing. Interstingly, since the issue dealt with text messaging and shortcodes, the story was picked up not only by pro-choice and anti-censorship news carriers and blogs, but by sites like Ars Technica and Slashdot.

Sticking to the technology theme, the website Facebook recently started banning pictures of women breastfeeding from user accounts, and in some instances has banned specific users altogether (for example, Karen Speed from Australia, who has chronicled the entire event on her blog, One Small Step for Breastfeeding). Facebook banned certain pictures on account of their “obscene content” and asserted its right to remove pictures as a violation of its terms of use policy, but as the Sydney Morning Herald points out, it’s not exactly clear what constitues an “exposed breast”, which is the specific violation, and Facebook hasn’t provided any further. clarification. Right. So, breastfeeding is obscene, and women aren’t allowed to post their own pictures of themselves breastfeeding on their own facebook accounts. If this bothers you as much as it bothered me, go join the new facebook group entitled Hey, Facebook, breastfeeding is not obscene!

In other news, a 43 year old Russian woman has recently given birth to a 17 lb. baby, her 12th baby to date. Wow!!

Finally, this is a quick reminder to local folks that the 5th annual Miles for Midwives will be occurring this weekend, Oct. 6th, at Prospect Park. The 5K run/walk helps to raise awareness for midwifery, as well as raise money for the ACNM local NYC chapter, and Friends of the Birth Center. My beloved boy and I will both be there, of course, running and sweating in the sunshine. Race time is 10:00 am, rain or shine. If you’re interested in joining the race, you can register at Active.com.

Finally, the long-awaited SUNY Downstate Gala will be occurring this coming weekend, celebrating 75 years of continuous midwifery education. SUNY Downstate is actually the oldest and longest running midwifery program in the country, and is commerorating the event by a day-long educational symposium featuring speakers such as well-known author Barbara Katz Rothman and keynote speaker Joyce Thompson, CNM, followed by a dinner-dance. Sounds amazing! Go Downstate!

The next educational session I went to was on sexual dysfunction, presented by a doctor who has spent years heading up a sex clinic in downtown Chicago and mentoring other medical and nursing students in sex therapy. While she had many, many (often sad, often hilarious) fascinating stories to relate, she really didn’t get into the nuts and bolts of sexual dysfunction in any great detail, at least not in any way that is immediately clinically applicable in terms of helping, counselling and treating couples with dyspareunia, anorgasmia, vaginismus, unconsummated mariages and premature ejaculation (although apparently you can use SSRIs, which notoriously have libido-killing side effects, to help delay and slow down men who have rapid ejaculation problems). Still, it was overall a fascinating topic, and really made me realize how little I know about sex therapy and sex counselling, which is indeed something a midwife should be pretty well versed in. While I certainly feel comfortable asking women about their sex lives, and discussing all aspects of sex and a person’s sexuality, specific treatments and counselling techniques are not at all in my repertoire, which is something that can be fixed with a little bit of reading and education.

The third educational session I attended was Menopause: Case Studies of Hormone Therapy, which was fabulous. I was astounded by how well the researchers knew the material. They made the very valid point that even though the Estrogen/Progesterone arm of the Women’s Health Initiative (WHI) was ended in 2002 due to the alarming increase in the rate of breast cancer, the other arms of the trial continued, and information is still pouring in from all sides, as well as from other studies that are now in progress. One of the speakers (Mary Brucker, CNM) termed it “research sushi”: after a large randomized control trial such as the WHI, you’re often left with more questions than answers, and in the ensuing years different aspects of the larger study are often chopped up (like sushi) into more specific questions and newer, smaller studies are mounted to try to tackle all of the questions raised. With hormone replacement therapy (HRT) at the moment, we’re apparently very much in the research sushi phase. It’s still a very grey, very unclear and ambiguous area, with very few clear guidelines or answers. While the WHI did a great job of scaring people so much that HRT is now often avoided at all costs (even when it can be very beneficial on a short-term basis for symptomatic relief of menopause), some of the information gleaned from WHI is actually, surprisingly saying the opposite. While the combined estrogen/progesterone arm increased the risk of breast cancer, apparently the estrogen alone arm of the study actually had no increased risk in breast cancer among the women treated with estrogen , and and a nearly significant decrease in risk (28% in the estrogne-alone arm, v. 34% in the placebo arm), which raises the question of whether all hormones are bad, across the board, period, end of story, or whether some hormonal therapy might actually have a very valid place in symptomatic relief (it also raised the question of what to do about women receiving unoposed estrogen without progesterone to balance it out, which has been shown to increase the risk of endometrial cancer). As you can see, very confusing stuff. They also delved into alternative treatments, such as the use of soy and phytoestrogens, Tibolone (which is used in Europe and actually had a worse Relative Risk for developing breast cancer than the combined and estrogen alone arms of the WHI), and compounded, bio-identical hormones, which also might not be the be-all-end-all cure that they are often touted as. Really, really fascinating stuff. I wish I was better versed in all of this, too, but I still find menopause and HRT very confusing.

Today started bright and early after a fairly late night dinner with a few other student midwives from Florida and North Carolina, mostly spent comparing our program experiences, mutually stressing about the board exams, and reviewing test questions that one of the students had from the test prep workshop she’d attended earlier that day. This morning I attended a great lecture on the Social Marketing of Breastfeeding, and how commercial marketing techniques can be very effectively used to market breastfeeding, especially when you break it down in terms of product, pricing, placement and promotion. She had all kinds of examples of ads from formula companies, which we then deconstructed in the class to root out the hidden, and often very sneaky and damaging hidden messages in them. Again, realizing how important language is: using the word “breastmilk repleacement” instead of “formula”, which makes it sound like a far inferior version of breastmilk, rather than a special, carefully planned, secret recipe which is just as good as breastmilk. We also talked about the importance of not only talking about the benefits of breastfeeding, but the risks involved with not breastfeeding. Again, none of this was new to me, but it was a very well put together and very concise presentation, full of good tips and suggestions, and it has really inspired me to work harder on my breastfeeding promotion and education (“selling” this amazing product—breastmilk!).

The schedule got a bit messed up, there are a few announcements on room changes and cancellations and switching of times, so the lecture on hormonal contraception counselling which I really wanted to attend, I missed. Instead, I ended up in a fascinating discussion panel on the horrific health disparities which still exist in our country, and the ways that midwives can work harder to amend these. We watched a small section of an upcoming PBS special entitled “Unnatural Causes: Is Inequality Making us Sick?”, which will air this winter in a 7 part series, and was incredibly eye-opening and terrifying in many of its implications. For example, the clip we watched demonstrated again and again that the areas of a county or city or state which have the lowest socioeconomic standing (which goes hand in hand with the highest crime rates) also have the highest rates of heart disease, pre-term birth, infant mortality, death by diabetes, hospitalization for asthma, lowest environmental standards, highest pollution and toxin exposure…the list went on and on. From the PBS website on the series:

Former U.S. Surgeon General Dr. David Satcher and his colleagues calculated that in 2002, 83,570 African Americans died who would not have died if black-white differences in health did not exist, a rate of 229 “excess deaths” per day. That’s the equivalent of one Boeing 767 being shot out of the sky and killing everyone on board every day, 365 days a year. And they are all Black. According to a by-now landmark study by Dr. Colin McCord and Dr. Harold Freeman, African American males in Harlem are less likely to reach age 65 than men in Bangladesh.

There are by now thousands of studies tracing the pathways by which racial and socio-economic status affect health. But there is virtually no popular media—no print, TV, nor web—that translate this research into forms that can build public understanding of how social policies are de facto health measures. As a result, the ‘common-sense’ wisdom remains that the poor and peoples of color get sick because they have unlucky genes, or they are just too lazy and undisciplined to to eat right, exercise and abstain frm drugs and booze. Similarly, it’s still widely believed that top executives who are dropping dead from heart and artery disease when in truth it’s their subordinates.

After watching the clip, we then moved into a very fascinating, (and very encouraging!) roundtable discussion. Midwives have always traditionally worked with underserved, indigenous populations, and it was amazing to hear about some of the changes and work that is being done around the country right now. You could feel the energy building in the room as people continued to come to the mircophone to speak. By the time the sesssion ended, the conversation had barely gotten started. Because the session is going to be repeated tomorrow, it was suggested that rather than starting over, we simply pick up the conversation again where we left off, which may or may not happen depending on how many people from today’s lecture attend the session tomorrow. In any case, though, I would watch the PBS documentary when it comes out, because it is going to raise A LOT of questions, and cause a media-world storm to descend on this long ignored issue.

Which now brings me to the present moment.  Time to find some lunch, and then sit in on an afternoon session review of the 2006 STD Guidelines (because, while I’m here, might as well attend lectures which will be useful on our board exam).  Tonight is the opening ceremony and dinner, followed by the long-awaited opening of the Exhibit Hall.  I can feel my money disappearing already.  Can’t wait!  Much more to come!

“I came across your website when I was google searching the words “Ina May” and hyperthyroidism. Reading a bit on your blog, I saw that you did a monstrous report on the condition. I have a ten month old baby girl (my first) and was recently diagnosed with hyperthyroidism (my TSH was .004) but have not yet been to an endocrinologist. My physician put me on atenolol, but I am still breastfeeding so I’m not taking it. Anyway, I was wondering what your report was about, and if you might have any suggestions that you could share. Many thanks in advance.”

Funny that you should ask about this, because we actually had our lecture on thyroid conditions during pregnancy today. My earlier report was on different thryoid conditions which are often seen during primary care of women (not necessarily during pregnancy), although today’s lecture focused only on pregnancy. My first suggestion would be to go to an endocrinologist as soon as possible. There are many different causes of hyperthyroidism, the most common cause being Grave’s Disease, which is an autoimmune disorder caused by thyroid stimulating antibodies. However, there are many other different causes of hyperthyroidism, running the gamut from pituitary tumors (very rare) to iodine-induced hyperthyroidism. This is why you’ll really need an endocrinologist to help figure all of this out; it’s complicated stuff, with many different etiologies.

Another thing to think about is when your symptoms first began. Was it before your pregnancy, during your pregnancy, or has it been only during the postpartum period? If only during the postpartum period, there might be another cause for the hyperthyroidism: postpartum thyroid dysfunction (also called lymphocytic thyroiditis or postpartum thyroiditis), which occurs in about 5-10% of all pregnancies. With this disorder, usually hyperthyroidism develops first, about 2-3 months postpartum, and will continue for up to 4 months postpartum, followed by a hypothyroid phase lasting 1-3 months. In 70-90% of all cases, this will usually resolve spontaneously without treatment, usually within 6 months. However, 10-30% of women with postpartum thyroiditis may have permanent hypothyroidism, so again, it would be a good idea to have an endocrinologist following this in order to determine the true cause of your hyperthyroidism, and whether it will resolve or not.

Treatments for hyperthyroidism usually include either PTU (Propylthiouricil) or Methimazole (Tapazole), both of which interfere with the synthesis of thyroid hormones by preventing iodine uptake. Both of these medications can be used during pregnancy AND are safe for breastfeeding. Atenolol (a beta blocker) was also listed in our lecture as one of the drugs used to help control the severe hypermetabolic symptoms of hyperthyroidism, such as tachycardia (fast pulse), tremors, palpitations and heat intolerance. Beta blockers are actually the treatment of choice for thyroiditis, and are safe to use during pregnancy. There is no contraindications to using beta blockers while breastfeeding. I just visited the website forum of Dr. Thomas Hale, one of the leading experts on pharmacology during breastfeeding, and looked up Atenolol. In this post, as you can see, one woman was concerned about the possibility of a baby having hypoglycemia after breastfeeding from a mother who was taking atenolol, but it seems that while atenolol might cause hypoglycemia in adults, he didn’t think it was present in breastmilk in suffiicient quantities to cause hypoglycemia in an infant:

I spoke with a Pediatric Cardiologist whom I greatly respect. He assured me that he’s used beta blockers and atenolol many times in pediatric patients and has yet to see hypoglycemia.It is true that in adult diabetics, it may induce hypoglycemia, but I’m reassured that his probably does not occur in infants, particularly from minor exposure via milk.He also told me that infants are apparently less sensitive to beta blockers and that even higher doses are sometimes required to be effective.So I’d look for something else causing hypoglycemia in your infants.

The thread on antihypertensives makes it very clear that beta blockers are fine during breastfeeding, so I think you would be okay taking atenolol and nursing at the same time. Medications in Mother’s Milk might be a really good resource for you.

Other treatment options for hyperthyroidism, if that is indeed what you have (as opposed to postpartum thyroiditis), include radioactive iodine treatment or surgery (partial thyroidectomy), but again, these are options best discussed with your endocriniologist.

I’m including a few resources here in case you want to look any of this stuff up yourself. These were some of the references from my presentation. Hope this helps!

Smeltzer, S., Bare, B. (2000) Metaboloic and Endocrine Function; Assessment and Management of Patient with Endocrine Disorders. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Lippincott, Williams and Wilkins: New York.

Reid, J., & Wheeler, S. (2005) Hyperthyroidism: Diagnosis and Treatment. American Family Physician, 72(4): 623-630.

American Association of Clinical Endocrinologists. (2002). Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Practice, 8(6):458-469.

Via Gothamist, New York City mayor Mike Bloomber has recently pledged $2 million dollars to city-run hospitals for the promotion of breastfeeding, with the goal of getting more women to breastfeed for six months or longer.

“We don’t yet have any hospitals in New York City that meet national ‘baby-friendly’ standards,” Bloomberg’s health commissioner, Dr. Thomas Frieden, said at a parenting conference last week.”That means getting formula out of the nursery. It means putting the baby on the breast immediately after birth. It means that every person who interacts with that mother and child is supportive and encouraging of breast-feeding.”

Well, three cheers for that! I can tell you, a boost like this is sorely needed, particularly in public hospitals, since research has shown that the rate of breastfeeding increases with income, education and age, and public hospitals most often take care of the women who have the least. I hope a fair portion of this money is spent not only advertising and promotion among the general public, but on education for hospital staff. Women need so much help and support in order to be able to breastfeed, especially during those early crucial days in the hospital, when both mother and baby are still learning how; the attitude and encouragement of the hospital staff, from the doctors and pediatricians on down to the PCAs and nurses’ assistants, is absolutely crucial.

For a long time, breastfeeding education and attention has been given short shrift, but thank goodness things are starting to change—from much-publicized public nurse-ins in places like Toys R’ Us to the Massachusets ban of hospital distribution of diaper bags loaded with formula coupons and advertising. The hospital where I am currently doing my clinicals (a public new york city hospital) has recently created a new policy where formula is never placed in a baby’s bassinet when the baby is brought out to the mother, even if the mother is breast and bottle feeding. If the mother wants formula, she has to specifically ask for it. Small steps like that, but the hopefully the overall impact is much greater.

Mothering magazine recently ran a competition to create an internationally recognizable symbol for breastfeeding. The winning symbol, created by graphic designer Matt Daigle, can be seen at the top of this post. This symbol has been made part of the public domain, so it can be downloaded and displayed anywhere, by anyone. The intention is not to segregate breastfeeding mothers, or to designate specific places for breastfeeding, but to simply indicate that breastfeeding is welcome and acceptable on the premises. Hopefully we’ll start to see this symbol cropping up all over the place, in restuarants and malls and airports and libraries, movie theaters and convention centers, maybe even on subways and buses….starting with our public hospitals (I’m going to print out a couple of these and bring them to clinicals tomorrow).

Crosstown bus: We board a M79 at midday, taking a seat opposite the driver. At the next stop, the bus starts to fill up and we get down to business.

The baby wriggles around, exposing a few inches of skin – and all around me, riders develop the kind of glazed-eye look usually reserved for panhandlers and the mentally ill.

Finally, one passenger pipes up, “Can you do that someplace else?” But she’s not talking to me – she’s barking at a man talking loudly on his cell phone.

When we get to the end of the line, the driver tells me I’m his first breast-feeder passenger. He’s not sure what the Transit Authority’s policy on nursing is, but he has his own. “I don’t see no objections to it,” he says.

Overall, it seems that most New Yorkers are pretty cool when it comes to public breastfeeding, although Connor’s nursing prompted an admonishment from a Babys ‘R Us worker, which the corporate spokeswoman was quick to point out went against store policy. Guess they learned a thing or two from their partner company, Toys ‘R Us, but it sounds like their workers could still use a bit more training.