Supporting Breastfeeding

La Leche League Canada

Second Time Around

on October 25, 2016

As I sit here breastfeeding my second daughter, Niamh, I am so thankful that I became a part of my local La Leche League group. Without the support, information and contacts of the group, my second breastfeeding experience may not have been so positive.

Like my first, my second pregnancy was hard won, though took less time to achieve than my first (two years to conceive as opposed to five for my first). As my older daughter was born prematurely at 30 weeks, we were thinking this time would be similar; the reason for the premature birth was due to my uterine anomaly (Uterus Didelphys) and reduced kidney function, as I only have one kidney and less room in my uterus for the baby to grow. So as soon as I found out I was pregnant again, I started taking low dose Aspirin pills and calcium pills daily. I found an independent midwife who had experience with high risk pregnancies, and was referred to the Obstetric team at Waikato Hospital, who wanted to see me when I got to 20 weeks gestation. From 24 weeks gestation, I was injecting myself daily with blood thinners (Clexane); my impaired kidney function (resulting in protein in my urine) and my age made me higher risk for blood clots in pregnancy. I had to continue this until six weeks after Niamh was born. It wasn’t something I’ve done before, and not being that fond of needles, I certainly didn’t enjoy it, but I tried to shut my brain off and “aim and stab”.

When the pregnancy got to, and past 30 weeks, I was almost just waiting for something to happen. I was having fortnightly blood and urine tests to monitor my kidney function. The levels were worsening, but so far manageable. I noticed on the weekend when I was 33 weeks pregnant, that my face/neck looked a bit swollen and puffy. It became more noticeable the following day. So I contacted my midwife and she got me in for a blood pressure check. My blood pressure was fine, but she wanted me to have a blood test done along with my fortnightly kidney function tests which were due that day. My midwife phoned that evening and said my kidney function results had deteriorated in the past two weeks, so I needed to go to Women’s Assessment Unit to be admitted for observation.
I was admitted to hospital on the Monday night. On the Tuesday my Obstetrician came to see me and said she wasn’t happy with the test results, and that she would rather deliver my baby now to preserve the kidney function I had. The Renal specialist wasn’t quite so concerned, but after much consultation between the two specialists, it was decided that my baby would be delivered by elective Caesarean section first thing Wednesday morning.

Newborn2

Fortunately this time I was awake for the delivery (my older daughter was born by emergency c-section with me under general anaesthetic), so it was quite a surreal experience having open abdominal surgery while still awake. It was all very leisurely and relaxed, even though I felt on edge. I got to see my baby briefly as she was taken across to the resuscitation table, then again as she was taken out to the Neonatal Intensive Care Unit (NICU). I got to see her properly for the first time two hours later, when I’d been given the all clear from recovery. I was wheeled on my bed down to NICU and Niamh was taken out of her incubator to have a skin-to-skin cuddle with me. She was on Continuous Positive Airway Pressure (CPAP) to help her breathe. Even though I had been given steroid injections a week before to help mature her lungs for a potential premature arrival, because it wasn’t her that initiated labour, her lungs hadn’t had time to start adapting to life outside.

As I had been through the premature baby experience before, I knew I needed to start hand expressing colostrum for Niamh to be fed through her feeding tube. My midwife helped with the hand expressing on day one, I think the first syringe was only 0.1 ml of colostrum. Most of the rest of that day was a blur as I was dosed on pain medication. By day two, my hand expressing was getting a bit more volume. On day three I started using the electric pump.

Niamh was being given small amounts of my milk as it was available. She was also on a glucose drip to keep her blood sugar up. As she tolerated the milk, her volumes were increased, and the glucose reduced until she was only on breastmilk by nasal gastric tube.
She was able to come off CPAP on day five, and was put onto high flow oxygen to give a little bit of assistance. Day six was a milestone day, I was discharged from hospital, (which is one of the hardest things I’ve now had to experience twice, with each of my children, leaving my baby in the hospital), Niamh went off any breathing support and was maintaining her body temperature, so could come out of the incubator and into a cot (and into clothes!).

With my first daughter, pumping every three hours in the day and once overnight didn’t result in enough volume, so this time I was pumping every three hours in the day and twice overnight, setting an alarm to wake me to pump. The amount I was expressing wasn’t great, but was slowly increasing every day. While Niamh was in NICU I was only just keeping up with her scheduled feed demands, which put stress onto the expressing, and needing to get enough to feed her. I was also getting incredibly painful nipples from expressing; the breast pump fittings didn’t seem to fit me properly. A Lactation Consultant let me have a different type of fitting, and we bought another one the same so I could double pump, which helped immensely. I also hired a hospital grade double pump for using at home, to try and maximize the output and speed up the pumping sessions.
I knew from my time expressing with my older daughter, that I got a larger volume of milk after I’d had skin-to-skin cuddles with her. After reading up on the topic during my second pregnancy, and having a midwife who was very pro active in getting her clients to do skin-to-skin, I made sure that every day I spent at least an hour with Niamh skin-toskin. I only had to justify it once to a NICU Nurse, who suggested that Niamh would be “better off back in her cot”. I explained to her that I needed to have skin-to-skin cuddles with my baby, as it helped build my supply.

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When she was a week old, I tried our first breastfeed (she was 34 weeks gestation corrected age). She didn’t latch at all, and fell asleep at my breast, which wasn’t a surprise but I continued to try each day during our time spent skin-to-skin. One of the nurses gave me a nipple shield to try; they said that she was probably struggling to latch on because her mouth was so small. This made no sense to me, as my older daughter, who was more premature, had launched herself at my nipple when she was 32 weeks gestation corrected age, and started sucking. So I knew if a smaller baby could do it, then it was definitely possible. But I tried it, and it did seem to allow Niamh to have a deeper latch so we started using the nipple shield for every breastfeed attempt. I did notice that she had a dip in the end of her tongue, that made it kind of heart shaped, and remembered that being mentioned in a book one of my group leaders had lent me, called Making More Milk*, in relation to tongue ties, but I thought nothing more of it. I guess I assumed the NICU nurses would identify if there were any reasons why feeding wasn’t happening as it could be.

To be discharged from NICU, Niamh needed to be fully suckle feeding (breast or bottle), and gaining weight. So that became my goal. At just over two weeks old, I asked the charge nurse if I could try demand feeding Niamh when I was at the hospital, at my breast only without giving any expressed milk through her nasal gastric tube (NGT), and then see how long she went before waking for her next feed. We’d give her a top-up after the last feed I was able to be there for, to try and ensure she would last the three hours till her next scheduled feed (which the nurse would do).

She agreed that we could try this for two days, and if she had gained weight in that time, then we could room in. So I would feed her at the breast when she woke, which would be around every three hours, then pump, and then be back beside her for when she next woke. I was able to be there for four of her scheduled feeds on both of those two days, and she had gained weight during that time, so on the Saturday we were allowed to room in. Rooming in is where you stay in the hospital (they have dedicated rooms for mothers of NICU babies) and have your baby with you 24/7, and you do all the feeds and cares. If the baby gains weight during that time, you are discharged.

Our first day of rooming in, Niamh kept pretty much to three hourly feeding, at the breast with no top-ups. She was weighed the next morning, and had only gained 9 grams. My midwife said they like them to be gaining a minimum of 20 grams a day before they allow discharge. The second night we roomed in was pretty hectic. Niamh wanted to feed constantly, would scream if not feeding, screamed when trying to feed, and we both hardly slept. In desperation, I went to the nursery and got one of the NICU nurses to make up a 20 ml bottle of my expressed milk for her. I wanted to solely breastfeed, so was very upset at having to resort to a bottle at this point.

The weigh in after the second night was exactly what we needed; she had gained 22 grams so we were allowed to take her home. She was two weeks and five days old (36 weeks gestation corrected age) weighing 2,041 grams.

That should have been the end of the challenges, if my older daughter was anything to go by. I was expecting to come home, and just have her needing to feed and grow. But it wasn’t to be that straight forward.

My midwife came to see us on our first day home, she weighed Niamh, and while it was a “gain” in numbers, when she factored in Niamh’s vest and nappy and different scales to the NICU ones, the “gain” was actually very minimal. She then checked in Niamh’s mouth and said that she was fairly certain there was a tongue tie and that we should consider whether or not to have it snipped. I took her to the hospital the following week, where the Lactation Consultant confirmed a type 3 tongue tie, and she snipped it.
My midwife came to see us at home over the next few days. Niamh continued to gain, but incredibly slowly, with barely 10 grams a day, which my midwife was concerned about. So she suggested that we start supplementing with my expressed milk, and that I pump after as many feeds as possible to build up supply. The hope was that once her tongue tie was snipped, feeding would improve, and supply would improve.

So I started pumping after every feed, I was already taking several different herbal supplements, taking the medication Domperidone, and doing breast compression while pumping. We re-hired the double pump for a month, and I would double pump, then single pump each side while doing compressions, after every breastfeed. Yet the amount I was expressing didn’t seem to be increasing.

Since I wasn’t producing enough extra milk to meet the amount suggested by my midwife, I had to make a decision on what to do; Niamh wasn’t gaining weight well, though she wasn’t quite deemed “failing to thrive”. Our options were to use either donor breastmilk or formula to make up the shortfall for top-ups, until my supply increased and Niamh got stronger at feeding. I wanted to avoid using formula this time, as I had used it for one bottle a day with my older daughter, and wanted to trust that my body would do it this time. I discussed milk donation with my husband, and we decided we’d try. Through some contacts we found two mothers who were happy to donate milk to Niamh. I didn’t need much as the potential shortfall was only around 20-50 ml a day but it was a massive relief to have the donor milk available. I could now focus on trying to build my supply, knowing I had a back-up option ready and waiting if needed. In the end, I only needed to use 100ml of it; with a frequent pumping schedule I managed to just keep my expressing (and Niamh’s weight gain) on track.

 

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During all of this, I was still pumping after every feed. We decided to do the night feeds solely by bottle to try and maximize sleep. My husband would feed Niamh, and I would pump. We had to set an alarm to wake us up so we could feed her, as she wasn’t waking on her own, and with minimal weight gain, she couldn’t afford to go too long without feeding. I was getting increasingly concerned about my supply, as I was struggling to get 50 ml in total during these night time pumping sessions. When I was doing the same for my older daughter, I was getting 100 ml. I continued on with the galactogogues, Domperidone, and herbs, which had helped before, but nothing seemed to be working this time. It was then that my group Leader asked me what medication I was on, so I said only the blood pressure medication, Enalapril. That was our Eureka moment. My group Leader had consulted with Alison Barrett (IBCLC, Obstetrician), who found information which stated that when post-partum women were put on Enalapril (an ACE inhibitor) in the first 12 weeks, their breastmilk production could be impacted, with prolactin levels being reduced by 20%. The studies she looked at suggested this would happen at a dose of 20 mg/day, which is what I was on. So I then swapped my medication back to the pregnancy safe Labetalol, and the change was incredible. The day after I stopped taking Enalapril, I got 80 ml during my night time pumping sessions, then the next night I got 100 ml, then 120 ml. The blood pressure medication was the cause of my shocking supply. It also explained why I could pump the most volume in the late afternoon, but very little overnight, as I was taking the pill at night before bed, and by the afternoon it had worn off.

That wasn’t the only challenge we faced. Two weeks after Niamh came home, she started showing signs of Gastroesophageal reflux. My older daughter had had reflux, and was on medication for it until she outgrew the need so I recognised the symptoms immediately. We were checked at the hospital to make sure there were no physical issues at play, and were given the all clear.  So in addition to pumping after every feed, I now had a baby with reflux who would scream in pain after every feed, didn’t like to lie down flat, and had to be held upright after every feed for 20-30 minutes to try to keep the milk down.

I knew that in many instances reflux could be a result of physical issues, so I had my Osteopath treat her. She helped with realigning her body, though it didn’t appear to help the reflux. The Osteopath did however improve her breastfeeding. Even after her tongue tie was snipped Niamh still couldn’t poke her tongue out. But once the Osteopath treated her tongue, she instantly poked it right out, and could latch without a shield.

I then wondered if the reflux may be caused by food sensitivities as I had discovered while pregnant that I had sensitivities to certain foods. After keeping a food diary for a week, and noting what foods I’d eaten, and any symptoms I experienced, then what symptoms Niamh had, I was fairly sure that wheat and dairy were issues. When she was two months old I took her to my Naturopath, who tested her, and identified all the foods she is sensitive to, which along with my suspicions of wheat and dairy, were; gluten, soy, beef, pork, peanuts, cashew nuts and yeast. So I then cut them out of my diet, and within a few days, she was no longer screaming in pain after every feed, and we stopped medicating her for reflux.

Her growth has continued to be in the realms of “slow and steady”, with a predictable 20 grams a day. She is happy and healthy in all other respects, and developing in line with her corrected age.

I later discovered that she had an upper-lip tie, and that some of her tongue-tie had either come forward or reattached, as she regained the dip in her tongue. Breastfeeding was becoming uncomfortable as she was not able to latch properly and couldn’t flare her lip out. We subsequently had it revised by laser and her latching and feeding is greatly improved.

It has been an interesting and stressful learning curve, and while some of the aspects of our journey together are similar to the experience I had with her older sister, there are many more that are different. My husband was a wonderful support, and he took over a lot of things like doing the pre-school run with our older daughter on the two days she went, and keeping the house running.

With the difficulties that we’ve experienced, if Niamh had been my first child, I do wonder if I’d have been able to overcome them or find the support to work through them. I only discovered my local La Leche League group when my older daughter was 13 months old. Through the information I’ve gained (from the group meetings and group library books) and the support of the Leaders and other group members, I am pleased to have overcome our difficult start, and gone on to have another rewarding, loving breastfeeding relationship with my child.

* The Breastfeeding Mother’s Guide to Making More Milk, by Diana West, may be in your local LLL group’s library, and is also available through lllc.ca on Chapters Indigo.

 

by Alison Stacey
Used with permission from LLL New Zealand http://www.lalecheleague.org.nz/Websites/laleche/images/PDF_Downloads/Aroha_articles/Aroha_vol_15_iss_4_Second_Time_Around.pdf

 

 
If you need more information or have a breastfeeding problem or concern, you are strongly encouraged to talk directly to an accredited La Leche League Leader. In Canada, Leaders can be located by clicking http://www.lllc.ca/find-group or Internationally http://www.llli.org/.

If you have found this article helpful, La Leche League Canada would appreciate your support. Your donation is essential and very much appreciated to help LLLC cover the cost of producing breastfeeding resources: https://www.lllc.ca/donate or become a LLLC Friend http://www.lllc.ca/join-lllc-friends

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