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Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 1
Working and Breastfeeding
Made Simple
Nancy Mohrbacher,
IBCLC, FILCA
~
I earn royalties from
sales of breastfeeding apps & books
I accept no funds from violators of the
International Code of Marketing of Breast-milk
Substitutes
~
~I receive speaker fees
for talks like this
Disclosure:
CHICAGO
Windy City?
• Planning during
pregnancy
• Maternity leave
• Milk norms
• Breast & bottle
differences
• Meeting
long-term goals
• Troubleshooting
Overview
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 2
Planning
During
Pregnancy
Where to Start
• Ask coworkers: “Has anyone breastfed while working here?”
• Ask HR if a lactation program exists
Consider Work Schedule Flexibility
� Part-time
� Job-sharing
� Flex-time
� Phase back part- to full-time
� Compressed work week (same hours, fewer days)
� Work from home, telecommute
� On-site day care,
bring baby to work
Doesn’t have to
be all or nothing
• Creative use of vacation, sick days
• Privacy screen in manager’s office
Employer Solutions
http://www.womenshealth.gov/breastfeeding/employer-solutions/index.php
Options & Resources
Maternity
Leave
Know the Law
Legal requirements
to receive paid maternity leave
If no paid maternity
leave, what must your employer
provide by law?
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 3
Return to Work by Baby’s Age
≤5 wk Cluster feeding common, fussy times, milk ramping up, ~8-10 milk removals per dayfor full supply, recovering from childbirth
6 wk to 3 mo
Milk supply at max, peak fussy times, average of 4 childbirth-related symptoms
4-5 mo Fussy times subside, if back to work now, more likely to breastfeed longer
6-8 mo Solid foods started, baby begins to need less milk
9-11 mo More solids, less milk, can transition to cup
≥1 year Most stop pumping at work, leave other milks/drinks for baby, breastfeed at home
Baby Arrives: Milk Norms
Knowing how
breastfeeding works
simplifies life
Clarifies what needs
attention &
what can be ignored
1st 40 days,
milk ↑quickly
• Day 1: 1 oz/30 mL
• 5 wk: 25-35 oz/
750-1050 mL
Milk removal
is main driver
of supply
A breastfed baby’s milk intake:
↑Increases from
Birth to Week 5 Hill, et al. J Hum Lact 2005;
21(1):22-30
↔ Plateaus til 6 mo
↓Decreases when other
foods started
Peak milk intake averages ~25-35 oz/750-1050 mL per day
From 1 to 6 mo breastfed babies
need ~same amount of milk per day
Because babies’ growth rate slows
Nielsen, et al. Pediatrics 2011; 128(4):e907-14
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 4
Understanding Milk Production
Puts Mothers in Control of Their Experience
Know 2 Key Dynamics
Drained breasts make milk faster
Full breasts make milk slower
(FIL + pressure)
#1 Degree of Breast Fullness
Daly, et al. Exp Physiol 1996; 81:861-75
Language of Milk RemovalsOn average,
babies take ~2/3 of the
milk
available
To increase
supply,
babies take more milk
more oftenKent, et al. JOGNN 2012;
41: 114-21
#2 Breast Storage Capacity
Based on
volume of milk in
the breasts
at their fullest time
of the day
Not about breast size
Affects # milk removals per day needed to build & maintain supply
Daly, et al. Exp
Physiol 1993;78:209-20
Newborns’
tummies are small, so
Storage Capacity
may not be obvious till after
1st month
Photo: Nils Bergman, MD, MPH, PhD
Bergman. Acta Paediatr 2013; 102(8):773-77
Takes more time for breasts to
get so full that milk-making slows
May not need to remove milk often (or at all)
at work to maintain supply
Large Capacity
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 5
Takes less time for breasts to get so full that
milk-making slows
Must remove milk
more often to maintain supply
Small CapacitySimilar to…
Concept: Jeanette Panchula, BSW, RN, PHN, IBCLC
# Milk Removalsper Day Needed to:
Largest
Capacity
Large
Capacity
Medium
Capacity
Small
Capacity
Smallest
Capacity
Increase milk 4-5 6-8 8-10 10-11 ≥12
Maintain milk 3-4 5 6 7 8
Decrease milk 2 3 4-5 6 7
Clues to Storage Capacity
Largest
Capacity
Large
Capacity
Medium
Capacity
Small
Capacity
Smallest
Capacity
Max pump yield
10-12 oz300-360 mL
5-9 oz150-270 mL
3-5 oz90-150 mL
2-3 oz50-90 mL
1-2 oz30-60 mL
Max longest stretch
10-12 hr 8-10 hr 7-8 hr 6-7 hr 4-5 hr
Good idea to wait 3-4 wk before
introducing bottle
Pump to comfort
as needed
Top priority: getting in sync with baby
Milk Expression During
Maternity Leave
Oversupply pros:
• Extra milk to store
Oversupply cons:
• Flow struggles
• Breast fullness
• Need to express
• Risk of mastitis
To Build a
Work Freezer Stash
Start storing ~3-4 wkbefore return to work
At work, milk pumped can be fed next day
Pump 1x/day = milk for
first day + reserve
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 6
Pumping Averages
Baby’s Age Average If Pump
Replaces Feed
Average If Pump After or Between Feeds
First week
(after Day 4)
1-2 oz30-60 mL
0.5-1 oz15-30 mL
2-3 weeks 2-3 oz60-90 mL
1-1.5 oz30-45 mL
1-6 months 3-5 oz90-150 mL
1.5-2.5 oz45-75 mL
http://www.nancymohrbacher.com/blog/2012/11/27/how-much-milk-should-you-expect-to-pump.html
Kent, et al. Pediatrics 2006; 117(3):e387-95
Hands-On Pumping (HOP)http://newborns.stanford.edu/Breastfeeding/MaxProduction.html
Increase in Milk Yield
>48%Morton, et al.
J Perinatol 2009; 29(11), 757-764
Milk-fat content
nearly double the averageMorton, et al.
J Perinatol 2012;Jan 5; 1-6
Image: Jane Morton’s DVD: Making Enough Milk
Available from www.breastmilksolutions.com
Hands-On Pumping
1. Massage both breasts
2. Double pump
3. Stop pumping &
repeat massage
4. Single pump or hand express
5. Alternate right to left
to right, etc. until milk flow slows
http://www.nancymohrbacher.com/blog/2012/6/27/to-pump-more-milk-
use-hands-on-pumping.html
Breast & Bottle Differences
Older babies
may transition to a cup
Introducing a Bottle
There’s LOTS more going on
than baby’s age, type of bottle
used
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 7
On maternity leave:
• How often to bottle feed?
• How much to give?
Think “snack” rather
than “meal”
• 1-2 oz/30-60 mL per day
• Every 2nd or 3rd day
Peterson & Harmer. Balancing Breast & Bottle: Reaching Your Breastfeeding Goals. Amarillo, TX: Hale Publishing, 2010.
Bottle flows
faster, more consistently
• Can override
baby’s appetite control mechanism
• Contributes to overfeeding, obesity
Li, et al. Arch Pediatr Adolesc Med 2012; 166(5):431-36
At an average feeding, formula-fed babies
consume much more milk:
• 49% more @1 mo
• 57% more @3 mo
• 71% more @5 mo
& feed fewer times per day
Kramer, et al. J Pediatr 2004; 145(5):600-05
For the average
breastfed baby, feedings do
not vary much
in number & size from 1 to 6 mo
Kent, et al. Breastfeed Med 2013; 8(4):401-07; N=52
Fewer & larger
feedings over time is a
bottle-feeding
pattern
To avoid
overfeeding use pacing &
slowest flow
nipple/teat
For pacing details, see handout: For the Caregiver of a Breastfed Baby
Kassing. J Hum Lact 2002; 18(1):56-60
www.NancyMohrbacher.com/handouts/
Back to Work: Maintaining
Milk Supply
Long Term
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 8
Expand your
focus beyond
number of
pump sessions
at work
Focus on 24-Hour Day
~ 30 oz/900 mL
per day needed
After 1 month,
an average
breastfeeding is 3-4 oz/90-120 mL
The Magic Number
Total # of milk
removals per dayneeded to maintain
production
long term
Main factor: Breast Storage Capacity
Mohrbacher. Clinical Lactation 2011; 2(1):15-18
If baby is exclusively breastfed, after 6 wk count # breastfeedings per 24 hr
A clue to storage capacity
And # milk removals per day needed to maintain long-term supply
Daily milk removals = breastfeeds + pumps
After returning to work, try to keep stable daily total of milk removals
Many mothers pump enough at work but don’t breastfeed enough at home
As daily total drops,
milk production slows
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 9
MORE
BREASTFEEDING
when together means
LESS PUMPED MILK
NEEDED
when apart
= 3-4 oz/90-120 mL
LESS milk
needed at work
Every breastfeeding
added
= 3-4 oz/90-120 mL
MORE milk
needed at work
Every breastfeeding
dropped
Reverse cycle nursing
• Breastfeed most when mother’s home
• Longest sleep stretch when mother’s at work
Impact of the Longest Stretch
Always ask its length
“Full breasts
make milk slower”
Usually at night
– May be ≥12 hr
– 8 hr works
for some but not all
# Milk Removalsper Day Needed
to:
Largest
Capacity
Large
Capacity
Medium
Capacity
Small
Capacity
Smallest
Capacity
Increase milk 4-5 6-8 8-10 10-11 ≥12
Maintain milk 3-4 5 6 7 8
Decrease milk 2 3 4-5 6 7
Daily Milk Removals & Supply
Largest
Capacity
Large
Capacity
Medium
Capacity
Small
Capacity
Smallest
Capacity
Max longest stretch
10-12 hr 8-10 hr 7-8 hr 6-7 hr 4-5 hr
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 10
Calculating Baby’s Milk Needs
~30 oz/900 mL in 24 hr
Mother’s away 8 hr
• 8 hours is 1/3 of 24
• 1/3 of 30 oz/900 mL = 10 oz/300 mL
Average—may be more or less
Assumes baby feeds at night
~30 oz/900 mL in 24 hr
Mother’s away 12 hr
• 12 hours is 1/2 of 24
• 1/2 of 30 oz/900 mL = 15 oz/450 mL
If apart 8-12 hr, baby needs
~10-15 oz/300-450 mL
Assumes baby feeds at night
816
8 hr sleep = 30 oz/900 mL in 16 hr
12 hr sleep = 30 oz/900 mL in 12 hr
1212
If Baby Takes Much More, Find Out Why
Bottle too full, milk discarded
Over-feeding
Too little breast-feeding
The Magic Number
Many mothers pump enough at work, but don’t breastfeed enough at home
As daily total
drops, milk production
slows
Troubleshooting
with Employed
Breastfeeding
Mothers
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 11
“My baby is taking more milk than
I pump at work. What should I do?”
~What is your first response?~
Before answering, ask:
• Volume of milk expressed
• Volume of milk fed
• Times per day she:
– Breastfeeds
– Expresses milk
• Magic Number when
home & daily total now
• Length of longest stretch
• 24-hr routine
May Also Need to Know…
• Is baby eating solids?
• Pumping issues?
‒ Pump quality, malfunction, fit
‒ Milk-ejection issues
• Galactogogues used?
• Mother or baby health issues, meds
(birth control)?
1: Jen & Colin
“My baby is taking
more milk than I pump at work.
What should I do?”
Baby Colin 10 wk old
Jen@work full-time 2 wk
1: Jen & Colin
Magic Number @home: 8
Apart 8 hr
• Colin taking 20 oz/600 mL
Jen can’t keep up
• Jen pumps 12 oz/360 mL
Expected volume
• 8 hr apart = 10 oz/300 mL
• Colin taking twice the milk expected
1: Jen & Colin
Breastfeeds 1x am, 2x pm, pumps 2x at work, sleeps 8 hr at night
• Now daily total = 5 (Magic Number 8)
Colin is fed four 5oz/150 mL bottles
• 1 at arrival at caregiver
• 2 during day
• 1 just before Jen arrives
What is the issue? What can Jen do?
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 12
2: Abby & Beth
“My baby is taking more milk than I pump at work. What should I do?”
Baby Beth 6 mo old
Abby@work full-time 4 mo ago
2: Abby & Beth
Milk issues @3 mo
Magic Number @home: 8-10
Early, Beth slept 10-12 hr
Abby@work 4 mo ago, apart 8 hr
• Milk dropped right away
• Pumped at night so as not to wake Beth
• Used herbs to boost milk production
2: Abby & Beth
Abby dropped night pumps• Longest stretch: 10-12 hr
When herbs stopped, , milk supply drops, uses formula
Dropped feedings over time
Now daily total = 5 (Magic Number: 8-10)
• Pumps 2x at work, breastfeeds 3x at home
• Pumping 6 oz/180 mL in 8 hr at work, Beth takes 12 oz/360 mL in 8 hr
What is Abby’s issue?
3: Josi & Claire
“I pump less milk at work than I used to. What can I do?”
Baby Claire 8 mo old
Back to work full-time 5 mo ago
3: Josi & Claire
Magic Number: 8
Josi@work 3 mo, away 9 hr
Milk stable until ~6.5 mo
• Pumped 12 oz, now 9 oz
• Daily total now: 8
• 3 pumps@work + 5 BFs@home
• Longest stretch: 8 hours
What’s affecting supply?
3: Josi & Claire
What caused the change?
Milk intake
• Increases birth to Week 5
• Plateaus (until ~6 mo)
• Decreases with solid foods
Questions to ask:
• Is Claire on solid foods?
• If so, how much?
Does Josi need to increase her milk?
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 13
To Increase
Milk Production
The sooner, the better
Increase daily total of milk removals
• Breastfeed more
• Pump more
Drain breasts more fully each time (Drained breasts make milk faster)
− Use hands-on pumping
− Check pump fit Jones & Hilton. J Neonatal Nurs 2009; 15(1):14-17
If using milk from freezer stash every day,
find out why & adjust
To wean off,
• Pace all bottle feeds
• Gradually reduce extra milk while breastfeeding more
• Pump at home
Breastfeeding Does Not
Have to Be All or Nothing
One Size Does Not Fit All
Tailor strategies
to different:
• Jobs
• Babies
• Family dynamics
• Maternity leaves
• Storage capacities
• Body responses to pumping
Knowing how
breastfeeding works clarifies what
needs attention &
what can be ignored
• Planning during pregnancy
• Maternity leave
• Milk norms
• Breast & bottle
differences
• Keys to meeting long-term goals
• Troubleshooting
Working & Breastfeeding Made Simple
©2016 Nancy Mohrbacher, IBCLC,
FILCA 14
www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC
Pinterest.com/nancymohrbacher@BFReporter
www.YouTube.com/NancyMohrbacher
~