Nursing During Pregnancy!

Congratulations! You just found out you are pregnant! And with all those new emotions of excitement and anxiety you have another thought in your mind: What about my current nursling? What am I going to do about breastfeeding? You go to your doctor for your first prenatal check up and are met with a frown and "Well, you probably want to consider weaning now." You leave feeling sad and confused, not wanting to wean your child yet. The good news is that most women do not have to wean during pregnancy! So why are so many women told to wean when they become pregnant? There are a few myths still floating around about nursing and pregnancy. The biggest is that nursing during pregnancy can cause miscarriage. There is absolutely no proof that this is true. The theory is that nursing causes nipple stimulation that can release the hormone oxytocin to the uterus, which causes contractions. The human body is smart however. Early in pregnancy, your body protects the uterus from the oxytocin. While you may feel some uterus tightening during nursing, this is normal and the same muscle tightening that occurs after sex sometimes. While miscarriages do happen in 15 - 30% of pregnancies, they are not caused by nursing. Another reason doctors tell mothers to wean is because your body will take nutrients from the baby. Again, this is not true. A mother who eats a healthy well balanced diet should have no problems nursing through pregnancy. You will want to make sure to eat enough calories in a day to cover not only the baby's calories but the breastfeeding ones as well.

This may be difficult in the early months, when morning sickness is a factor. It also depends on the age of your nursling. If s/he is only six months old, s/he will be nursing more for nutrition than if your nursling is 2.5 years old. You won’t starve your baby or your nursling if you aren’t interested in eating a lot of things. However, you should take care not to become dehydrated. If you are having trouble eating at least 1800 calories per day, or if you are suffering from repeated vomiting episodes, please seek medical attention.
What are the big concerns when nursing through pregnancy?

An excellent resource for nursing through pregnancy and tandem-nursing a newborn and an older child is Hilary Flower’s Adventures in Tandem Nursing.

http://store.llli.org/public/profile/77

First off is supply. During the first trimester, your supply will start to decrease and will continue to decrease and may even disappear. Not all mothers completely dry up, however most do notice a dramatic drop in supply. This is because your body is changing the milk from mature milk to colostrum. It is normal towards the end of pregnancy for your supply to again increase. If your nursling is under 1 and still primarily getting their calories from breastmilk, you need to keep an eye on your baby. If you start noticing a dip in weight gain or a decrease in wet diapers you may have to consider supplementing with donor milk or formula. It is not advised to take supply-boosting supplements during

pregnancy! Most galactogogues are also emmenagogues, which mean that they promote menstruation. Therefore, they are not to be taken during pregnancy. Some babies will wean during pregnancy due to the decrease of milk and the change in taste.

Another concern during pregnancy is sore nipples. This can happen at any time and usually comes and goes in waves. It can become very painful to nurse at times! When the pain occurs, how painful it is, and how long it last will vary from women to women. At this point some women choose to wean because it is too uncomfortable to continue. Some women also will set time limits on nursing sessions if it becomes too uncomfortable. The good news is that for many women, this discomfort lasts only a short time. Don’t feel bad about setting loving limits with your nursing child. You will be helping them develop a sense of self and independence for many years to come. This is only the beginning. There are very rare instances where weaning during pregnancy is recommended. If you are suffering from pre term labor or having severe health issues during your pregnancy, it may be best to consider weaning your nursling. Most women however can continue to nurse through pregnancy and even during labor! Don't be surprised if your child’s nursing behaviors change through the course of your pregnancy. Many of our admins have nursed when pregnant!http://kellymom.com/nursingtwo/resources/pregnancynursing-faq.pdfhttp://www.lalecheleague.org/nb/nbjulaug00p116.html

Foremilk Vs. Hindmilk

Many moms worry about the fat content of their milk. They hear from their friend that they had a foremilk hindmilk imbalance and that it caused issues. They pump and see only a super thin layer of “fat” atop the container and then see a picture of a woman with a huge fatty layer. The instant reaction is “oh my gosh, something is wrong!” 

First, lets clarify the terms. Foremilk is the milk your baby initial gets when they start feeding. This milk is usually low in fat. Hindmilk is the milk that the baby gets at the very end of the feeding, usually high in fat content. Why is there a difference in milk you ask?

Human breastmilk is actually all the same. The difference in milk comes from the fact that the fat globules in the milk stick together and collect further in the back of the breast. As the baby nurses and the milk moves from the back of the breast through the nipple the fatty globules move forward with it. 

This is also why the mistaken idea that longer time between feedings causes fattier breastmilk is NOT true. As your breasts refill the less fatty milk gets moved to the front while those fat globules get pushed back. Longer times between nursing means more foremilk and less fat. Shorter times between feedings means the baby is getting more of the fatty milk because those fat globules are closer to the nipple. 

IMPORTANT NOTE: YOU CAN NOT TELL FAT CONTENT OF MILK FROM PUMPING. The layer at the top of the milk is NOT an indicator of how much fat is in your milk. It is simply the milk separating into layers. Even foremilk which is less fatty will have a layer on top. Do not gauge your milks fat content by how pumped milk looks. The only way to do this is to have the milk professionally analyzed. 

Make sense? 
Many moms think that milk suddenly switched from foremilk to hindmilk. This however is just not the case! Kellymom describes the process as turning on a hot water faucet. “The first water you get out of the tap isn’t usually hot, but cold. As the water runs, it gradually gets warmer and warmer and warmer. This is what happens with the fat content in mom’s milk – moms’s milk gradually increases in fat content until the end of the feeding.” (http://kellymom.com/bf/got-milk/basics/foremilk-hindmilk/) 

Still not sure exactly what is being said. The blog the funny shaped women did an amazing job visually showing the difference between foremilk and hindmilk and the gradual progression that occurs! She pumped and took small samples at various points in her session and then had the samples analyzed for fat, calorie, carbohydrate, and protein content. The results show that over time slowly the milk increases in fat and calories, its not a sudden abrupt switch from foremilk to hindmilk.http://thefunnyshapedwoman.blogspot.com/2011/05/foremilk-and-hindmilk-in-quest-of.html

So what does all this mean to moms? 
When nursing your baby you want to let them finish the first breast first before switching. Many moms are still told to only nurse for X number of minutes per breast. Remember all moms produce milk different and produce milk with a different fat content. Also all babies nurse differently! While one baby may be satisfied by the first breast after 5 minutes another may want 10, 15, or even 20 minutes. If your baby pops off try burping and reoffering the same side. If your baby pops off again chances are they are done with that side. At this point most moms should offer the second side, even if your baby only nurses on that side for a few minutes. A large majority of babies nurse both sides per nursing session.http://www.llli.org/llleaderweb/lv/lvsepoct95p69a.html

There are situations however when women don’t want to offer both breasts. If your baby is constantly having frothy green poop then you may have too much milk and your baby may be getting too much of the less fatty foremilk and not enough hindmilk. There are other signs of oversupply as well, usually babies are gassy and fussy, tend to “chug” when nursing, pull away from the breast after letdown occurs (usually resulting in milk spraying everywhere!), and sometimes will actually have a shallow latch to help “slow down” the milk flow. At this point you may want to consider offering the same breast for 2 feedings in a row. This allows your baby to get more of the fatty milk out because your breast is not having as much time to refill between nursing sessions. This is called block or flex feeding. http://kellymom.com/bf/got-milk/supply-worries/fast-letdown/

Before jumping to the oversupply conclusion however ask yourself some questions: Does this happen all the time? Has anything changed recently? Did my baby just go through a growth spurt/has been nursing more frequently? Its normal for newborns to go through a growth spurt, nurse a lot, and end up taking in a bit too much foremilk. If you are not having all the symptoms listed above consistently then it may just be temporary. As I said, most moms offer both breasts per feeding. 

So what is the take home here? 
- Milk does NOT magically switch from foremilk to hindmilk!
- Watch your baby, not a clock! Let your baby nurse from the first side first, don’t rush them to move on! 
- Most moms should be offering both sides for each nursing session! 
- 99% of the time, you don’t have to worry about foremilk vs hindmilk. If your baby is nursing well and gaining well then everything is going great!

Breastfeeding after surgery or while on medications

If you are going to be needing health care, medications, dental work or surgical procedures, you may be worried about how you are going to manage caring for yourself and caring for your young child at the same time. If your treatment plan includes oral, IV, intramuscular or topical medications, you may be concerned about how those medications will affect your baby. You may have been told by your care provider that you will need to pump exclusively and dump the milk for a period of hours or days as the medication leaves your system. Your doctor may tell you that they will not prescribe you narcotics for after-care unless you agree to exclusively supplement with previously-expressed milk or formula while you are on those meds.

The good news is that this information is outdated, and usually incorrect. Most medications used to treat a wide variety of injuries and conditions are perfectly safe for breastfeeding. When you receive advice from your care provider that makes you wonder if it’s correct, ask yourself the following questions:

Did they tell me it was OK to take this medicine while pregnant?
Did I receive this medication while in labor or recovering from the delivery?
Is this drug routinely prescribed to infants with a similar condition?

If the answer to any of these is “yes,” then the likelihood is high that the medicine you have been prescribed is safe for breastfeeding. But since that’s not a guarantee, check out Lact-Med (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT) or The Infant Risk Center (www.infantrisk.com) if you are not absolutely sure.

The second link takes you to the website of Dr. Thomas Hale, considered the world’s foremost authority on breastfeeding and medicine use. He has a wonderful app which is available for both android and iphone so that you and your doctor can look at medications together to find something that is a good fit. If you are a breastfeeding mother, this app is a MUST. http://www.infantrisk.com/apps

Now, let’s cover some basic categories you might be facing.

Antibiotics
Most are safe for both mom and baby. Not 100% of them are safe, and some are safer than others. Make sure to talk with your care provider and InfantRisk. Sometimes a care provider can give you a few options for antibiotics and you can choose the best for your situation. 

Dental Work
Dental work, again, is usually fine. Most of the anesthetics used are local anesthetics, which do not pass into your blood stream as general anesthetics do (or else they would not be local). X-rays, fillings, crowns, even root canals should be fine. Make sure to double check with InfantRisk to double check! 

Surgery
Ah, the big one. Most surgeons and anesthesiologists, knowing very little about breastfeeding, will tell you to pump and dump for 24-48 hours after going under general anesthetic. Today however we know that in most cases this information is outdated. Ask your doctor and anesthesiologist what medications they are using and call InfantRisk. They can give you information on how long the medication will be in your system. 

The other concerns you may have about the baby are more related to scheduling. If you are nursing frequently during the day, but will be separated from your baby for many hours, you will need to pump or at least hand-express to avoid discomfort and risk of blocked ducts or mastitis. It is best to pump or nurse the baby shortly before your surgery begins, and then afterward as soon as you feel comfortable enough to do so safely. If your surgery will be long or your access to baby and/or pumping will be limited, it may be wise to contact an IBCLC in your area to discuss ways to manage the condition. If your condition is not severe or life-threatening, you may be able to put off the surgery until your supply can accept going several hours without nursing or pumping.

For your care after the surgery, plan to have help on-hand. Depending on the procedure, you may not feel up to caring for your baby or other members of your household for a few days. Arrange to have someone to help make it easy for you to just lay in bed and nurse. If you have residual pain, say from an incision site, be sure to take your pain medications on time. Set a timer if necessary, or ask someone to watch the clock and bring you your dose at the appropriate hour.

Pain meds
Many moms feel uncomfortable taking pain medication, especially prescription ones, while breastfeeding. Often times doctors will flat out tell moms they can not take it. The good news is that in most cases this is NOT true. Discuss with your doctor what kind if pain you can expect and what the recommended pain medications are, and then call InfantRisk to discuss the pros and cons of each. Remember: Many mothers today have c-sections and will nurse immediately after surgery in recovery. These moms are sent home with pain medication to help them recover and continue to breastfeed.

One big thing to consider, especially with strong pain medication, is that you should not bedshare with your baby. These medications often times cause drowsiness which makes bedsharing dangerous. Make sure you have worked out a plan for night time parenting if you typically bedshare. 

Having to spend a lot of time caring for your own health can be difficult and frustrating when you have little ones at home. But with some research and planning, you can get the treatment you need and still be able to continue nursing your baby.

Alternative Feeding Methods

So you're going back to work in a week. Today, you busted out the bottle and the 85 million nipples you bought....and none of them work. Baby is refusing to take a bottle and nothing is going to convince her otherwise. 

This happens a lot. And it's impossible to know which babies will take a bottle gladly, which babies will develop nipple preference, and which babies will refuse to take them. It honestly doesn't matter when you introduce the bottle, although some IBCLCs suggest 4-6 weeks being an ideal time to try if you are planning to go back to work or school. Some babies just don't want an artificial nipple once they've tried the real thing.

A couple of tips to try and get baby to take the bottle:
--Have someone other than the owner of the boob attempt to bottle feed. If baby knows the boobs are there, they'll likely want it from the tap.

--Sometimes having dad or grandma bottle feed while wearing a piece of mom's clothes helps baby to settle

--It may only be possible to get baby to take the bottle if mom leaves the vicinity entirely. Take this as an opportunity to get your nails done, enjoy a coffee and a couple chapters of your favorite book, or park somewhere and call a friend who you haven't been able to get more than 5 minutes on the phone with. When you get back, you'll know if baby needs the boob or not (if baby takes the bottle for a full feed at this point, remember to pump so as not to negatively effect supply). 

--Try offering the bottle when baby is sleepy (just before bed or upon waking up).

http://www.motherandchildhealth.com/Breastfeeding/Becky/breastfed_bottle.html

http://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/

If baby will absolutely not take a bottle, please do not add this to the list of things us moms have to be anxious about. There are other ways to feed baby while you are at work or school. Please read this over and over again **YOU ARE AN AWESOME MOM FOR CONTINUING TO OFFER YOUR BABY BREASTMILK WHILE YOU ARE WORKING OR AT SCHOOL**. How baby gets this milk may vary and that is OK!!!!!! 
http://www.medela.com/IW/en/breastfeeding/products/breastmilk-feeding/special-feeding-devices.html

Here are some alternative way to feed an infant breastmilk:

By cup - http://www.youtube.com/watch?v=4ZCm_MhP39M Not only is this baby super adorable (my poor ovaries), but this video clip is an awesome example of feeding a baby by cup. Start with a small amount of milk. .5-1oz is plenty to help baby get the hang of it. You can always add more milk. This process should be slow and at baby's own pace. Hold baby in a semi-upright position and bring the cup to rest gently on bay's bottom lip. Slightly tip the cup so that baby can lap or sip the milk, but do not pour the milk into baby's mouth. Make sure baby is calm, maybe even a little sleepy, when starting this process. Do not wait until later hunger cues for this method.

By syringe or dropper - Again, hold baby semi-upright and make sure baby is calm and possibly a little sleepy. Fill syringe or dropper with milk. Place the syringe or dropper to baby's lips to encourage baby to open their mouth slightly. Pushing the syringe/squeeze dropper very slowly so that just drops come out. Baby will "suck" milk into their mouth, and may try to suck on the syringe or dropper. This process should be very slow and at baby's own pace. do not put syringe or dropper far into baby's mouth or release more than a few drops at a time into baby's mouth.http://www.mother-2-mother.com/refusingbottle.htm

By SNS/finger feeding - This can be done with an SNS and tubing, or a syringe with tubing. http://www.saskatoonhealthregion.ca/pdf/breastfeeding_finger_feeding_feeding_tube.pdf This article does a great job of explaining the process and easiest way to finger feed with tubing.
Also http://www.nbci.ca/index.php?option=com_content&view=article&id=5%3Afinger-and-cup-feeding&catid=5%3Ainformation&Itemid=17

When finding a caregiver for your breastfed baby, this is a really great "skill" to look for; an individual who is experienced in alternative feeding methods rather than just bottle feeding. This can also be helpful if mom chooses not to introduce the bottle to avoid nipple preference. Many moms go back to work or school and never introduce a bottle, only using the methods described above for alternative feeding when not at the breast. 

http://kellymom.com/bf/pumpingmoms/feeding-tools/alternative-feeding/

Growth Curves

The day has come and your baby has been born! Congratulations! Everyone is calling and looking for the “the details”; they want to know what time and where baby was born, but also on their mind is how big baby was. You happily announce the details, regardless of baby’s size; and then the comments start rolling in. And everyone has a comment, from your mother, to your best friend to your great aunt Marge. They will tell you how big their babies were and compare your baby to their baby. They will remark about how big or small, short or tall baby is. The game is on.

Actually the game has been on since before baby was even born. You may have come across unthinking friends or even strangers that commented on how big your belly was, and thus how big your unborn child is. Your doctor may have felt your stomach and estimated baby’s size. You may have been talked to about scheduling a cesarean because baby was going to be “too big” to birth vaginally. Or you may have been put on bed-rest and have had baby’s growth monitored because baby was measuring “too small”.

How big baby is before birth and how big baby is after birth and through the first two years have little to do with their stature as an adult.

A growth chart of a baby not following
a growth curve

Growth charts were not designed as a test. There is no gold sticker for a child who is at the 99.9% curve for their weight and height and the child at the 5% curve is certainly not bringing up the rear. Growth curves were designed to provide statistical information about the growth of children. This isn’t school. Having a child that is at the 50% isn’t a failing grade. Having a child at the 50% means that 50 out of 100 children would be bigger than your child and 50 of them would be smaller. It is that simple, and sadly many doctors don’t think to explain the charts this way. Rather as a new parent you often feel a sense of letting your child down because they aren’t at the 99.9%. This is not the case; you are not failing by any means by not having a “super sized” child. (And as a mother of a 2 year old that is larger than most 4 years old I can honestly say it is not easy having a child that large.)

There are a few important factors to notes about growth curves –

1) There are 2 growth curve charts still in use in the US.

a. One of the CDC one which was developed before 1977 when formula feeding was all the rage. This chart is referred to often times as the “formula chart”.

b. The other chart is the WHO one which was developed using statistics (remember these charts are just that statistic markers) of breastfeed babies. This chart is often referred to as the “breastfeed chart”.

2) Make sure your child’s doctor is using the correct chart. Remember you are the only one that can speak up for your child, so make sure you do.

3) These charts are different in reflecting that fact that breastfed children typically (but not always, remember this is statistical information) grow more rapidly in the first two to three months than their peers that are formula fed. These charts are reflect the inverse in the following three to twelve months.

Another very important fact to remember; babies size at birth does in no way indicate what their growth curve should be. A baby born at 10 lbs. is not expected to remain off the charts for weight for the rest of their life. Conversely a baby born at 4 lbs. is not expected to always be the smallest in their class. Many factors can influence a baby’s size at time of birth. These things ranges from heavy use of IV fluids in the laboring mother, cesarean or rapid births, pre and post term births, and maternal medication conditions (such as diabetes). When looking at a newborn’s weight gain it is IMPORTANT to reflect on their lowest weight (typically 24 to 36 hours after delivery) in order to determine how well they are gaining. A baby that lost 20% of their birth weight cannot be expected to double their birth weight in the same amount of time a child that lost only 3% of their birth weight did.

When looking at a growth chart it is important to see that the baby is following THEIR growth pattern, and not necessarily a particular growth curve. A chart that has a lot of hills and valleys in it should be addressed, and reasons for those spikes should be looked at. A baby that is continuing to lose weight

and is rapidly dropping off the growth curve should also be monitored, as should a child that continues to climb and climb in size off the chart. These are things your doctor should be looking for and explaining to you when reviewing your child’s individual growth patterns.

As a child nears the age of two their growth will begin to follow more a particular curve, and their height at age 2 is estimated to be about half of their adult height. That being said all children hit puberty and have growth spurts at different ages, but in the end they will have followed THEIR growth curve to a particular height. Also, as your child gets older your doctor will start monitoring their body-mass-index (BMI) and charting this as well. This is in an effort to combat the obesity epidemic in the US; but as we know people come in all shapes and sizes.

This is why it’s OK to have a baby that is long and lean, or short and round, or round and long, or short and lean. As long as they continue to follow the INDIVIDUAL growth patterns that routinely indicate this.

Lastly, please remember you are looking at an infant’s weight gain in ounces. An ounce isn’t very much at all. If you child had a massive blow out diaper right before getting weighed this could look like a blip on the screen. Alternatively if your child just had a full breastfeeding session before getting weighed then could weigh in many more ounces than you might have expected. The same goes for ensuring that your child is always being weighed naked. A wet diaper and or a cloth diaper add a lot of weight when you are comparing ounces. This also goes to the fact that weighs should always be done on the same scale, a difference in calibration can through off weights by a few ounces as well. If you combine all of the possible deviations here, you might expect a weight to be off by as much as a pound.

Additional recourses on weight gain and growth charts:http://kellymom.com/health/growth/growthcharts/ http://www.cdc.gov/growthcharts/clinical_charts.htm https://iotacharts.com/en/public/info/language

Alternative Milks

So your baby is approaching a year, the point past which you’ve been told it’s okay to start introducing cow’s milk or another alternative milk into your baby’s diet. Maybe you’ve been told you should wean at one year. You certainly don’t have to, and there are countless reasons to continue breastfeeding into the second year. But that’s a subject for another TOTD. Today, we talk about alternative milks.

As you may be aware, the World Health Organization recommends that this be the choices in milks for a mother to feed her infant. They are ranked in order of priority:
1. Breastmilk from the mother’s breast.
2. The mother’s breastmilk, which has been expressed and is then given to the baby in a syringe, bottle, or cup.
3. Expressed milk from another breastfeeding mother.
4. Commercial infant formula.

You may be wondering where other commercially-available alternative milks fall in this classification. If you’ve done your research on the contents of commercial infant formula, you may assume that cow’s milk, soy, almond, rice, coconut or other alternative milks fall somewhere between 3 and 4. Surely these milks are safer for babies and toddlers, right?

Unfortunately, this is simply not the case. If your child is under the age of one, and you have exhausted every attempt to provide your baby with breastmilk from your breasts or from other breastfeeding mother, formula is the WHO’s preferred alternative. You are not better off supplementing with an alternative milk. Any alternative milk, be it formula or almond milk, is going to fall significantly short of breastmilk, particularly in the child’s first two years of life. Let’s look at some of the fundamental complaints about infant formula:

• It is highly processed
• It is full of sweeteners and fillers to make it more drinkable
• It is heavily fortified beyond what the natural ingredients support
• Its nutritional content is deeply inferior to breastmilk

All of this can be said about almost any commercially-available alternative milk. The alternative milks that provide a composition similar to breastmilk are usually in the form of raw animal milks. However, these are usually expensive, unavailable in many parts of the country, and pose risks to infants and toddlers who have a milk protein allergy, which is a common problem. And, all the new alternative milks that are all the rage are really no better than formula. Some have protein but no fat, some have fat but no protein. Some have hardly any protein or fat or calcium.

That’s OK, you might be thinking. Apples don’t have a lot of fat or protein or calcium, either, but they’re part of a healthy diet. And that is true. If all you want is to pour a little coconut milk over your toddler’s cornflakes, you’re probably fine. Once a baby begins eating table foods in earnest (usually sometime after 12 months), the breastmilk vs formula debate becomes much more nuanced. The issue is quantity. If you ate an apple a day, you might be a very healthy person. But the healthiness of your apple consumption would change dramatically if half of your diet, day in and day out, consisted solely of apples.

When you are considering an alternate milk for your toddler so you can stop pumping or to simply have an alternative, aim to keep the supplementation at a minimum. None of the new alternate milks have nutrition adequate enough to make up half a toddler’s diet.

Lactation Support: One Size Doesn't Fit All!

One of the keys to having a successful long term breastfeeding relationship is SUPPORT. This support doesn't have to be from a certified professional, sometimes simply online support of someone saying "YOU CAN DO IT!" is all that you need. That being said, there are many times when seeing someone in person to help address a problem is needed. There are a few different places to turn to in this case!

First you have your local peer to peer support groups. Two of the biggest support groups are LLL (La Leche Leauge) and Breastfeeding USA. Most of the time you can find a  meeting within 30 miles of your house. Sometimes you have 2 or 3 locations to chose from! Each group is run by a leader who has applied and shown that she is a good fit to run the local group. LLL and Breastfeeding USA have specific criteria a woman must meet before she can become a leader. You can read all about how to become a LLL leader or Breastfeeding USA counselor here:https://www.llli.org/docs/lad/thinkingaboutleadership.pdf and https://breastfeedingusa.org/content/get-involved. Sometimes leaders may be trained lactation support professionals, sometimes not. If you are confused about something or concerned it is always a good place to start to look for help. LLL or Breastfeeding USA can help direct you. Many have phone numbers and email addresses online and can field calls nights and weekends. 

Secondly is your local hospital. Many hospitals now days have a lactation support group that is run by an on site lactation professional. These are similar to a peer to peer support meeting in that usually they are free to attend. The person running the group may be a certified lactation consultant or they may simply be a nurse with lactation experience. Many hospitals also now have a "warm line" that you can call to speak to a nurse for assistance. 

Last we have what most people have heard of: a lactation consultant. 

BEWARE: Just because someone says they are a lactation consultant does NOT mean they have all the certifications. Sometimes a nurse with some lactation experience can say "yes, i'm a lactation consultant!" 

When you meet a lactation consultant you want to make sure they are certified. Ask! Most are certified IBLCE (http://www.iblce.org/) . A breastfeeding counselor is most likely certified CLC (http://www.talpp.org/clc.html) . Even on hospitals own lactation staff they may not have anyone who is certified. You can locate certified lactation consultants online: http://www.ilca.org/why-ibclc/falc

No matter whom you are seeking breastfeeding support from in person, one of the keys is that YOU feel comfortable. If the advice of a professional or a peer support group doesn't sound right to you, question it. Don't take advice from someone just because they have more experience/a certification/are getting paid. Just like there are bad doctors there are also bad lactation consultants. Yes, even some with an IBCLC certification are NOT good consultants. 

A few warning signs to look for: 
- someone who belittles you or makes you feel stupid
- a consultant who touches you without asking first. 
- Someone who doesn't keep searching for an answer. IE: You keep saying you are in pain but they keep insisting that everything is fine so you have to deal with it. 
- someone who is not supportive. 
- someone who only offers band aid solutions without finding the real problem
- someone who tries to encourage you to "pump to measure output". 
- someone who tells you the 20 minute every 2 - 3hour rule.
- someone who you feel like isn't listening to you/helping you.

Lactation support can be expensive. While a support group is usually free a longer consultation with a certified consultant costs much more. The good news is that under the new health care plan insurance companies should cover the cost of lactation support. (http://www.medelabreastfeedingus.com/tips-and-solutions/142/lactation-consultant-coverage). It is best to call your insurance provider and find out what they will cover. Some may have an in network consultant to visit.

Alcohol and Breastfeeding

A big question that comes up after 9 long months of pregnancy and not taking so much as a Tylenol or eating a single piece of blue cheese; "Is it safe to drink while breastfeeding?" The easy answer is, yes. It can be safe to drink alcoholic beverages while breastfeeding. However that is not the full answer.

To answer this question we need to know a little more about how alcohol enters your system. Alcohol metabolizes through breast milk the same way it does through blood, at a blood alcohol concentration rate of about 15 to 20mg/dL per hour. This means that the alcohol will leave your breastmilk at the same rate it leaves your blood. Regardless of your size, alcohol metabolizes the same way. If you are a bigger individual, you may not feel it as quickly, but it will still leave your body at the same rate. For a 180lb female it takes about 2 hours per drink to completely metabolize. While yes, your breast milk doesn’t contain the dose of alcohol you ingested (less than 16% of the mothers dose), how much is in your milk will also depend on how much you drink. 

But wait, you said it was safe to drink when you are breastfeeding? 

Yes it is, however it is necessary to make good decisions in how you will plan out your evening if you do not want to waste precious breastmilk. Levels of alcohol peak in the mothers system 30 – 60 minutes after a drink is ingested and then will rapidly fall back to normal (as long as no further drinks are ingested). This means if you nurse and have a glass of wine or beer, chances are by the time your LO is ready to nurse again the alcohol will be mostly out of your system. The bigger concerns come when more than one drink is ingested. Two drinks over the course of 3 – 4 hours is very different than 2 drinks in an hour. If you wish to have more than one drink, plan appropriately. The more you drink, the higher your blood alcohol content, and the longer it will take for that milk to leave your system.  Remember: When we talk about a drink we are talking about a standard size drink. This means 12oz of beer, 5oz of wine, or 1.5oz of hard liquor. Not all wine glasses are the same, and it’s easy to overestimate what 1 drink really is.  What about the milk pumped when you feel you aren’t safe to nurse? Alcohol will only metabolize in breastmilk while in your body. The milk you pump if you are intoxicated will still contain alcohol after it has been pumped. If you do not wish to dump this milk then you should make sure to label it as not safe for drinking. 

But what about alcohol test strips? There is a lot of controversy around the alcohol test strips. They are promoted to moms to let them know that their breastmilk is safe. The idea is simple: you put a drop of your milk on the test strip and it will change colors if there is alcohol present. However, when you read the instructions, it states that the tests are
extremely sensitive. You will get a positive result with a blood alcohol level as low as 13.1mg/dL. This converts to a BAC of .013. For reference in most states the legal limit is .08. As you can see, you will get a positive result from very low levels of alcohol. You could get a positive just from eating a dessert that contains liquor! So while yes, these strips will accurately tell you if your milk as alcohol in it, they cannot tell you how much alcohol there is.

So what if you are planning to go out and drink more than one or two drinks? 

First off, ensure that your child is being left with a sober safe caregiver. If you are going out the choice is easy, but if you are drinking at home discuss with your partner who is going to be in charge of the baby. One of the big concerns with drinking alcohol as a parent is having a sober caregiver for your child. How you feel is no indicator of how intoxicated you really are. Plan on pumping milk before you go out so that you have breastmilk for your child when you are unable to nurse. Know that you will probably need to pump milk as not pumping or nursing can lead to clogged ducts and mastitis. Make sure to dump or label the milk you pump when intoxicated so that you do not offer it to your child later. 

PLEASE NOTE: IT IS NOT ADVISED THAT YOU BEDSHARE IF YOU HAVE HAD ANYTHING TO DRINK. EVEN ONE DRINK. 

Even if you think you are "ok", it is best to have baby sleep in a separate crib or bassinet. Everyone reacts to alcohol differently and even if you feel sober, it is very easy to sleep deeply and become a hazard to bedsharing.

DIRECTLY FROM KELLYMOM.COM
--Alcohol does not increase milk production. In
fact, babies nurse more frequently but take in less milk in the 3-4 hours after
mom has had a drink, and one study showed a 23% decrease in milk volume with
one drink (Mennella & Beauchamp 1991, 1993; Mennella 1997, 1999).
--2+ drinks may inhibit let-down (Coiro et al
1992; Cobo 1974).
One study showed changes in the infant’s
sleep-wake patterning after short-term exposure to small amounts of alcohol in
breastmilk — infants whose mothers were light drinkers slept less (Mennella
& Gerrish 1998).
--Daily consumption of alcohol has been shown in
the research to increase the risk for slow weight gain in the infant.
--Daily consumption of alcohol (1+ drinks daily)
has been associated with a decrease in gross motor development (Little et al
1989).

http://kellymom.com/bf/can-i-breastfeed/lifestyle/alcohol/

From Dr.
Hale: 

Facts:
1. Alcohol enters milk freely. 
2. One drink includes: 12 oz of 5% beer, or 5 oz of 11%
wine, or 1.5 oz of 40% liquor (80 proof). 
3. The peak level in milk is likely to occur about 1 hour
after consumption. 
4. Alcohol leaves the milk compartment as the mother’s blood
alcohol levels drop. 
5. Alcohol present in pumped milk is permanent. Discard the
milk. 
6. Waiting “about” 2 hours per drink is required for
complete metabolism of alcohol in a 180 pound female.
7. Techniques such as drinking more water, taking caffeine,
exercising, pumping and discarding of milk, etc. to enhance
metabolism/clearance of alcohol do not work. Only time will eliminate alcohol. 
8. Elixirs that contain ethanol can lead to blood alcohol
levels similar to those seen by taking one alcoholic drink. 
9. Storing milk before drinking is another way to make sure
your infant is not exposed to alcohol. 
10. Nothing can replace human breast milk as a source of
nourishment for your child; therefore, careful planning before drinking is
advised over formula use.
- See more at:
http://www.infantrisk.com/content/alcohol-and-breastfeeding

So what is the take away here? Moms absolutely can enjoy a glass of wine or a beer when breastfeeding. If you are ever concerned or question the safety of your milk, we would encourage you to always err on the side of caution. Please always drink in a responsible fashion.