My name's Elisabeth McLaury Lewin, and I'll be talking

today with Nancy Mohrbacher. She is an international, board-certified lactation

consultant and the coauthor with Kathleen Kendall-Tackett of Breastfeeding Made

Simple: Seven Natural Laws for Nursing Mothers. Nancy's also the coauthor of The

Breastfeeding Answer Book, which is a definitive encyclopedia of breastfeeding

information, which is used by doctors, nurses, lactation consultants and breastfeeding helpers around the world. Nancy's the lactation consultant for Ameda Breastfeeding Products at Hollister Incorporated, and she's been helping breastfeeding families since 1982. Elisabeth McLaury Lewin:

It's generally accepted as fact that breastfeeding is best for

babies and that it's completely natural. But lots of mothers look around, and they see

their friends and their own mothers and grandmothers having given up because they had really hard problems in the early days of breastfeeding. If breastfeeding is such a natural, normal thing, why do so many women have problems?

That is really a wonderful question, and I think we did discuss in one of the other podcasts that one of the major obstacles I think that women have is the fact that most of us didn't grow up seeing breastfeeding as a normal thing. If we lived in a culture where we saw it all the time, we would know now to do it. It wouldn't be something that we would have to learn. And, in fact, one of the major researchers in breastfeeding tells a wonderful story about how he asked an Aboriginal mother in Australia how she learned to breastfeed. And her answer was "I've always known how to breastfeed." It's very hard when mothers have problems because they don't necessarily know who to turn to and what to do about their problems, and they don't know what breastfeeding is supposed to be like or even what it's supposed to look like. I know when I first got involved with breastfeeding 25 years ago, a lot of what we taught breastfeeding mothers in those days sort of mimicked what we knew about bottle feeding because that's what we knew. All of us, I know I certainly did, grew up watching babies bottle fed.

For example, what we taught mothers on how to hold their babies to breastfeed was to held them with their stomachs facing the ceiling, holding them in arms, which is really a bottle feeding position. And then we were told to tickle the baby's cheek until the baby turned his or her head and latched on. That led to a lot of pain during breastfeeding. So a lot of moms who are starting off with breastfeeding have bottle feeding as their model. And a lot of times she try to use what they know to make breastfeeding work and, just like what I experienced, it really doesn't translate very well. I think we have learned a lot about babies' instincts to feed in recent years, and we talked about that in "Tips For Getting Off to a Good Start." Babies are born with some physical instincts. We've seen videos of babies who can crawl up from the mother's abdomen to the breast and latch with no help. Just like all mammal newborns, our babies can do that. You know, cats do

The Ameda “Why Do So Many Mothers Struggle with Breastfeeding?” podcast

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Sure. And I know for many of us, we spend pretty much the whole nine months of pregnancy reading about pregnancy and reading about childbirth. I know from my own experience, I didn't spend a whole lot of time, and there wasn't a whole lot of information out there to figure out what to do to actually breastfeed the baby. There were a lot of things about when the baby got bigger and needed, you know, discipline and needed to be trained and that kind of thing, but I didn't know a whole lot, and there wasn't a lot out there, to figure out what was a normal natural thing about breastfeeding, and sure hadn't seen it just around growing up the way I'd seen lots of other aspects of childrearing. So, how can a prospective mom or a brand-new mom maybe avoid some of those problems that we've had in the early days of breastfeeding?

Well, I always used to share with moms who disturbed by their breastfeeding problems the story about a gorilla in an Ohio zoo. And the story goes like this:
This gorilla mom was raised in captivity and had never been around other gorilla moms and had seen gorilla babies. And when she had her first gorilla baby, she didn't know how to feed it and, in fact, held it so it was facing outward instead of towards her body, and the baby eventually died. And the zookeepers were trying to figure out what to do when she became pregnant again in terms of helping her learn how to feed her baby. And one of them came up with an idea that was really inspired. They invited mothers from the local breastfeeding mother-support group to come and sit outside her cage and breastfeed their babies, their human babies. And the gorilla mom, you know, watched in interest during this time, and when her second gorilla baby was born, she was able to feed her baby. And, you know, that story really made moms feel better about their own problems because they realized it wasn't even just human mothers who need to see it and learn about it that way. It's actually higher primates as well.

Yeah. So it really is like I've heard it described. It's a learned art. It's the most natural thing in the world, but if you've never seen it happen, it doesn't seem natural.

Right. It really puts you at a serious disadvantage. And, in fact, probably one of the best things a mom could do to avoid problems is to attend mother support groups. There are support groups through La Leche League and you can find your local support group through them by going on www.lalecheleague.org. Many hospitals also have mothers' groups that you would be welcome to attend, and some public health departments also have mothers' groups available. So, whatever our situation, you should be able to find somewhere where you can go where there are breastfeeding mothers and see this in action. Something else I think that's good to know about breastfeeding is it's not something that's best learned intellectually. There are some things we learn better in a head way, and there are some things that we learn better in a different way. You could call it either a heart way or a body way. I know my husband used to take karate, and he had to learn certain moves. They were call katas. And he used to tell me that he couldn't just read them in the book and learn them that way. He had to actually do it. He had to do the moves. And that way, he said, it got into his body memory. And so, learning breastfeeding, you know, in a sort of left-brained, analytical way isn't always the best way to go about it. One doctor, her name is Dr. Christina Smillie, who has helped us understand a lot more clearly about babies' instincts and feeding behaviors, has come up with a little different strategy for helping moms learn how to breastfeed, and that is to approach it more from a relationship standpoint. And those of us who have been in breastfeeding for a long time often have referred to breastfeeding as a relationship. So the thing to focus on is not really so much exactly what you're doing, you know, in terms of micromanaging breastfeeding, but more about your relationship with your baby. And what she has found as she's helped moms is that she uses some of the inborn feeding triggers that trigger newborn feeding behaviors, such as skin to skin. She has mothers hold their babies so that the baby is dressed down to her diaper and the mother has the shirt open so that when the mother holds the baby against her chest, you know, facing forward-- excuse me, facing her, that the baby can feel the mother's skin against her torso. And that seems to be a really important part
of the baby knowing what to do. Because breastfeeding isn't really all about what the mother does. It's really just as much about the baby and the baby's role. And I think this is something we've sort of neglected to understand until recently. We often talked about breastfeeding as a dance, but often we instructed mothers in such a way that made it sound like it was all their responsibility, and it really wasn't at all about the baby. And anyone who's ever breastfed a baby knows the baby has a lot to do with what happens. So now that we're understanding a little bit better about this, what we're finding is that by putting babies skin to skin like this against mother's chest, that they exhibit certain very predictable feeding behaviors that mothers can use to help breastfeeding go more smoothly.

Wow. And it's sort of the baby leading the way.

Right.

Because the baby, even though we may be a little clueless, it sounds as though the baby has a pretty good idea of what needs to happen. Nancy Mohrbacher: Exactly. Once those feeding triggers are put in motion, then what happens is the baby-- usually when the baby's facing the mother, skin to skin against her chest, the baby starts sorting bobbing her head against the chest and start lunging down towards the breast. And at that point, what Dr. Smiley says to the mom is just to help move your baby's bottom towards the other breast and help, you know, support the baby's hip and neck, and then help the baby get in good alignment so that the baby's nose is opposite the nipple. And then as long as the baby's still feeling that skin to skin against their torso, you know, pushed closely against the mother's body, then the baby really pretty much does it from that point on. You know, our babies, just like other mammals, are born knowing how to feed if they just get the right triggers. So really she focuses more on that relationship, on the mother, more like as a coach instead of as the one who's running the whole process.

And I think that's just a really neat, almost inspiring way to look at it, that it's not just about a food delivery system.

Right.

But it's about...

It's a relationship.

Building that thing that's going to be with you the rest of your life, and that then makes it also seem-- it's more important but it's less crucial that the food delivery thing be perfect at this exact second.

That's true. And what it does, too, is it takes the pressure off the mother to do everything "right." Because so many mothers get so anxious as they approach breastfeeding because they think this is like a critical test of their mothering

skills.

Exactly.

And so it makes them really tense and anxious, which makes the whole process more difficult and obviously less pleasant at the same time. And so, if they see it instead as something that their baby really has the ability to do and they're just
there in a support role for the baby, it makes it a lot more pleasant, and it takes a lot of the stress out of the process. So, that's something that we've really learned more about recently that I think can help make breastfeeding less of a struggle and help, you know, mothers to find it more enjoyable as well.

It's a different mindset.

It is a totally different mindset.

We're used to being really good at whatever we're doing.
We're used to being very accomplished, independent women. And it's humbling and also kind of sometimes humiliating to find yourself in a position where you have no idea. The world is turned upside down. It's wonderful to have this baby, but it's very confusing and daunting to want to do everything right, and it's embarrassing to have to seek help in case it's going-- it's not even easy to know exactly whether what's happening is normal and going all right.

That's correct. For a mom that's not familiar with breastfeeding, I think that's one of the things that can be very anxiety producing about it is not knowing if what's happening is normal or not. A lot of parents say, "My babies didn't come with an
instruction book, and I don't know what to think." And that's one of the reasons that my coauthor, Kathleen Kendall-Tackett, and I wrote Breastfeeding Made Simple.
Breastfeeding Made Simple is a book that focuses on sort of the big picture dynamics, because my feeling is many new mothers are too over-focused on the details, but they don't have the perspective in which to put them, and that also raises anxiety levels. And so, the idea here, just like understanding babies' hard-wiring, that's actually our law number one of our natural laws. The more you understand the big-picture dynamics, the more enjoyable the process is and the easier it goes, because these big-picture dynamics are actually the same dynamics that we lactation consultants use to help solve breastfeeding problems. So if you understand how they work, then you can make breastfeeding work more easily for you and your baby.

And there really is a wide range of what's normal in baby behavior, too.

Yes.

So, babies are hardwired to do what babies do, which is...

Which is to breastfeed.

Okay. And that's their normal thing. And that's not necessarily something that they do in measured doses at regular times.

Nancy Mohrbacher:

Right, right. And that's the other thing. I think a lot of mothers approach breastfeeding with very unrealistic expectations of what it's going to be like.
And so, I think being around other breastfeeding mothers is a great way to adjust your expectations. I was lucky enough to start going to mother-support meetings when I was pregnant with my first, and I learned so much from watching the mothers and babies breastfeed but also hearing about their experiences. And so, when I had my first baby, it didn't surprise me. And that really put me in a good situation because, you know, I kept hearing these mothers' experiences in my head, and it reassured me that what my baby was doing was okay.

It sounds like that helped to marry that left brain, all the reading that you did beforehand with some just...

The right brain.

Real physical, feeling things.

Right.

You'd seen that mom nurse that brand-new baby, and then when you had that brand-new baby, you could call that back.

Yes. It's one thing to read something on a page, and it's another thing to have a mother tell you her story and have the whole emotional context be there.
Because I think that, you know, breastfeeding really is more of a right-brained activity. You know, some of the things we learn with our right brain that work better that way. Just something like learning to ride a bike. I mean, imagine if you had to learn to ride a bike using an instruction manual, you know, that says "First push your foot this way, hold the handlebar this way." You would be a very long time learning to ride a bike. You might even give up in frustration, which is what a lot of women do with breastfeeding.

Another The Ameda “Why Do So Many Mothers Struggle with Breastfeeding?” podcast

Sure. And it reminds me of when I learned how to knit. I thought there was something wrong with me because I had a children's knitting book, thinking if it's a book that's about knitting that's designed for children, a grown woman in her 30s ought to be able to do it. And yet, I just couldn't get those three-dimensional
actions put into place by reading the diagrams. And so I put the book away, I took a two hour class, and that made it all make sense. And then I went back home and read the book, and then it made sense.

Then it made sense. Right.

Right. So have some good reference books on hand, have an internet connection on hand.

Right. One thing...

But go as much as you can in person and seek help or even just seek information beforehand.

Well, I think another thing that a mother can do before her baby is born is to find out what are her local sources of breastfeeding help. I mean, going to a

mother group, mother-support group is good because she'll meet people there that she'll be comfortable calling. I know mothers normally don't feel so comfortable calling a total stranger about their nipples after their baby's born. It really helps that it's somebody that you've met and have talked to face-to-face. But also find out who are the lactation consultants in your area. Many hospitals have lactation consultants on staff. Sometimes, though, they won't come and see you unless you ask to see them. Some of them, you know, already so many women delivering that unless a mother puts in a request, she won't see them. So, don't be shy about asking to see them. Also there are people like I used to be, a lactation consultant in private practice in the community. Sometimes they

That's true.

So, if you have all those support people on hand, then that puts

you in a good situation in case you need to call them. Also, we do have ameda.com, our website, that I've put lots of articles on to try to help answer some of the common questions. But I really don't think that there's a substitute for one-on-one help. And if you need to find a lactation consultant in your area, one way you can do that is to go on line to

www.ilca.org.

And that's the International...

Lactation Consultant Association. Right.

And that has, like, a directory.

It has a find a lactation consultant tab right on the home page, and

you press on that, you put in your zip code, and you can find somebody local who you

can call for help.

And there's probably no question too embarrassing.

I don't think so. I've never yet heard a stupid question. I doubt very

seriously if any other lactation consultant has, so.

So, you said that really the brunt of the questions that you

receive, the majority of them fall into two categories.

Right.

One has to do with worries about an inadequate milk

supply. And then the other is worry--or not really worry- but the reality of pain during

breastfeeding.

Correct.

Do people really have that many supply problems?

Well, when they've done research on it, they've found that many

women who are worried they don't have enough milk actually have plenty of milk. And

what it is is that the mothers are confused about how to know that they have enough

milk.

Sure. Well, you can't see really how much is getting into the

baby.

Right. And for those of us who grew up watching bottle feeding as

the norm, that seems to be a real obstacle for some moms. There are easy ways to

know. Probably the most reliable way to know is to have the baby's weight checked. And

once the baby reaching their low weight, which is on day 4 usually, then you start to see

a weight gain of about, on average, six ounces a week for the first three to four months.

Weight gain does slow down after that. But, if the baby is gaining normally, then a mother

can be sure that she has enough milk, particularly if the baby's exclusively breastfeeding.

Sure. And so weighing the baby is a great way to know. And

in those early weeks, typically a baby's supposed to go in pretty often for regular checks

anyhow.

Right. That is something that they should be doing at their doctor's

office anyway. But if a mother is really worried, she should be able to call and make an

appointment to bring her baby in for a weight check at the doctor's office. So that's one

easy way to tell. On a daily basis at home, I suggest that mothers count their babies'

stools. That's an easy way to see that the baby's getting the fatty hindmilk they need to

put on weight.

Well, yeah, say a little bit. I know we've talked about that in

the other podcasts as well, but it's important to know that the quality of the milk changes

not just as the baby gets older but throughout a single feeding, which is so cool.

Right. Typically what happens, especially if a mother's breasts, you

know, have a fair amount of milk in them, is the first milk that comes is what's called the

foremilk. And that's the thin, watery milk. The reason for that is because fat actually sticks

to the milk ducts in the breast, and so the first milk that comes out is usually fairly low fat.

As I used to say in my breastfeeding classes, the first milk is sort of like 1% milk, and

then it goes to 2%, whole milk, half-and-half, and then cream. And that creamy milk is

what we call the hindmilk. And that's the fatty milk that puts on weight for the baby and

also creates the stools. So if the baby gets to the point where they're having stools, at

least three to four stools a day the size of a quarter or larger, then that's a pretty good

sign that they're getting enough of that fatty hindmilk to gain weight well and to thrive.

More stools than that is absolutely fine. After six weeks, it can be okay for babies to have

fewer as long as they're gaining well. But in the first six weeks, you do normally see

those three to four stools a day when breastfeeding is going well.

And more often than not, there's at least once every couple

of days where the poop is so voluminous that it requires a complete change of clothes.

Sometimes that can happen, yes.

And though that's kind of horrifying when it first happens,

that's a good thing because you know that baby's certainly very full.

Right.

So that's a good thing. But you said also you get lots of

questions from moms who are experiencing pain when they breastfeed.

Right.

And your big rule is that breastfeeding should not hurt.

Right. There could be a small amount of discomfort that's normal in

the beginning. For some moms it's normal to have some discomfort in the first minute or

so after the baby latches on.

But that's just in the first few weeks of life.

In the first one to two weeks, I would say that that would be

considered normal. If there's intense pain, if the pain is lasting through the whole feeding,

or if there's damage to the skin on the nipples, then that is definitely a sign that

something is not right. And what that is normally caused by is the baby latching on too

shallowly. When I talked about this in breastfeeding class, I used to have parents feel

the roof of their mouth with their tongue, and right behind the teeth you'll feel there's

ridges there, and if you go a little further back, you'd feel that it's the hard palate; it's hard

and smooth. And if you go back even farther, you do feel it start to turn soft. And it's near

that area where it turns soft that we call the “comfort zone” in

Breastfeeding Made

Simple

. And that's where the nipple needs to go so there's no excess friction or

pressure.

So I'm feeling back in my big grown-up mouth, and I'm

thinking in a little bitty baby mouth that's taking in a lot of breast.

Right.

Not just the nipple but the areola around it as much as

possible, as far back as possible.

Right. The areola is that pigmented part around the nipple that's a

different color.

If you're feeling intense or sustained pain past that first

week or two and past that first minute or so of nursing, it could be that not enough of the

nipple is in the baby's mouth.

Not enough of the breast, right.

All of the nipple and as much of the areola as possible. But

are there any other things that could cause nipple pain? Sometimes that will pop up. You

know, things are going okay the first couple of weeks and then suddenly it doesn't feel

good.

Right. There can be other causes. Sometimes there can be ways

that a baby's mouth is made that might influence pain during breastfeeding. For example,

there's a little membrane under the tongue, and if it's too short, and it's called a tongue

tie, and sometimes if the baby can't move their tongue normally, that can be an issue.

And that's easily remedied by just relieving some of the

pressure and expressing a little bit of milk.

Expressing a little milk to soften up the breast is usually enough to

take care of that. Sometimes there can be other causes of nipple pain, as you say, if

there's been a period of comfortable breastfeeding, if nipple pain suddenly crops up, it

could be some sort of a skin problem, like an overgrowth of yeast, which, you know, we

sometimes call thrush. Or, you know, there can be other skin problems that can occur,

but these are usually fairly easily treated.

But breastfeeding really shouldn't hurt.

No. After that initial discomfort in the first minute or two for the first

couple of weeks, it should be completely comfortable. A mother should feel some tugging

but no discomfort at all.

So it sounds as though a lot of the most common difficulties

that moms encounter really have to do just with establishing breastfeeding and managing

it well.

Right, and understanding it.

By breastfeeding the baby often.

Right.

That breast should stay emptied out so that engorgement

doesn't occur. And then also the baby's full, so the baby's gaining well, so the supply is

working well.

Right.

Are there any other questions and problems that you see,

frustrations that you see with the moms that contact you in your work?

Well, I think it's difficult for moms who are in a situation where they

don't know other mothers who are breastfeeding. They may have family members who

have doubts about breastfeeding. I think in our culture sometimes breastfeeding is seen

as an accident waiting to happen. They're always being quizzed, "Are you sure you have

enough milk? How can your baby want to be feeding again so quickly?" You know,

there's lots of things that undermine a mother's confidence.

Especially when the people that you're closest to seem to

be questioning your decision.

Right. And I think during those early weeks especially, mothers are

very vulnerable, emotionally vulnerable to the people around them. And that's why when

we talked about tips for getting off to a good start, we talked about the role the dad can

play in terms of shielding mothers from people who aren't going to be supportive, limiting

visitors and making sure she gets help with everything that she needs for her daily life,

you know, all the chores and meals and, you know, all of that. So, I think mothers can get

discouraged easily if the people around them are not supportive or are frankly

unsupportive. Sometimes that happens, too. And that's where, again, mother-support

groups can be very helpful. When I attended my group when I was a young mother, I

often felt that it was an antidote to the rest of the culture. I used to describe it as a parallel

universe where breastfeeding was the norm. Because with other mothers who were

doing it, they understood how I felt. I could learn from their experiences. And I always left

feeling bolstered that whatever the rest of the world dished out to me that I could handle

it between then and the next month's meeting.

Sure. And what you say raises an important point.

Breastfeeding really is the norm, has been forever.

Yes.

And I guess that's one thing that kind of is humbling. You

think, well, cave women who couldn't read scientific journals, somehow they managed to

breastfeed their babies. You know, I'm an expert in my computer technology field and

yet I'm completely knocked to my knees by this, you know, five-day-old child who isn't

conforming to my expectations.

Right. And it's all about, as I said in the beginning, what we've

been exposed to in our growing up years. What did we see as a normal way to feed

babies? Like me, a mother is someone who all she's ever seen is bottle feeding, then

having that exposure to other breastfeeding mothers I think is really important in terms of

avoiding some of the common struggles. It's something that shouldn't be a struggle. But

in the culture that we live in, it often is a struggle.

So, is it worth overcoming those cultural hurdles? Is it worth

the discomfort of the first several weeks?

Yes. Absolutely. It is. I think when mothers are able to establish

breastfeeding, it's something that is very important to them. I was talking in the "Working

and Breastfeeding" podcast about the study of several hundred mothers who were

working and breastfeeding, and some of them said they wouldn't make the same choice

again, but in that case, those mothers said they would choose a different employment

option. Maybe they would stay home with their babies. Every other mother who said they

would do the same thing again said that breastfeeding meant a lot to them and their

babies. It was something that left them with a real sense of accomplishment.

It sounds like you've given us some wonderful ideas. I

mean, it's nice to know that those worries and problems for the most part are solvable

without too much trouble and that they're common. Because it's embarrassing to feel,

you know, like you've been overwhelmed with a problem that you can't solve. They're

solvable and not that freakishly unusual and really worth the hassle because that

momentary difficulty, once it's solved, pays off in spades.

Yeah. Mothers often have a hard time seeing their way clear of

solving their problems because they don't know how to solve it. They may try the things

that they think of, but they don't realize that there are people like me and like other

lactation consultants whose job it is to know the tricks to make breastfeeding work. Doing

the same thing over and over that's not working is not a way to solve your problem, but

going to somebody who knows how to solve your problem can help you get to the other

side and succeed at something that you feel so strongly about.

Well, there are good resources for expectant parents and

for new parents at ameda.com.

There are. And there are links, too, to the ILCA website there if a

woman needs to find breastfeeding help.

Thanks fantastic. Well, thank you Nancy. I think this will go

a long way toward helping people kind of overcome those hurdles and get on their way to

successfully breastfeeding.

Thank you, Elisabeth.