Monday, September 21, 2015

Thomas' Journey from Bottle-feeding to Exclusive Breastfeeding

Thomas' Journey from Bottle-feeding to Exclusive Breastfeeding:

A detailed account that may be of help to other mothers

I have been breastfeeding for nearly nine years, with breaks of only several months. I have breastfed five babies, three of whom had submucosal, posterior tongue ties, one of whom could nurse but developed severe limitations with eating solid foods, and two of whom couldn’t nurse at all without interventions, such as this essay describes. In addition to practical experience, I benefited from the education and certification process to become a La Leche League leader, attending those monthly meetings for about five years before retiring as a Leader.

New to learning about how tongue ties and lip ties can affect breastfeeding? One of the best introductory, overview articles is an interview of Dr. Bobby Ghaheri, M.D., by "The Milk Meg."

This is the story of my fifth baby, Thomas Vincent, whose tongue and lip ties prevented him from nursing, and his journey learning how to be an exclusively breastfed baby. I documented this--in possibly an over-long way!--because I think it will be helpful to someone, somewhere out there who wants to nurse her struggling baby. It may be the mom herself who reads this, or the grandmother or friend, or the doula or midwife, any of whom can share it with the mom.

N.B. This is a special interests blog post and I expect only those with this strong interest in lactation management are going to read it!

WEEK 1 (birth to 7 days)

Even with all my experience with babies nursing normally and abnormally, I was in such a postpartum, hormonal fog that I needed my husband and several friends to tell me that I needed to hire an IBCLC to help Thomas. He wasn’t passing his meconium quickly enough (only one dirty diaper per day): wet diapers don’t count nearly as much as poopy diapers because ‘poop indicates calories!’

Happy birth day! 8 lbs 3 oz

At four days old, I began supplementing him with expressed milk using a blunt syringe; he belatedly transitioned to green poop at five days old and the much-anticipated ‘yellow seedies’ at seven days old.

At five days postpartum, I'd called an IBCLC (international board-certified lactation consultant) for an appointment and sent my husband to rent a hospital-grade breast pump and transfer scale before the lactation consultant even could come out to us: I knew the drill, I knew what was coming.

There are three necessary components to breastfeeding:

  1. production of milk, 
  2. getting the milk out of Mama (her anatomy), and 
  3. getting the milk into Baby (his anatomy). 

A breakdown at any point in that chain results in a baby who is not getting enough milk. In the case of a baby with a tongue tie, the initial problem is getting the milk into Baby, but that results in a failure of Mama producing enough milk: no demand, no supply.

While trying to determine and fix the problem, Rule #1 is to feed the baby. An important and sometimes overlooked fact is that, while older babies who get hungry will cry vociferously, newborns who get hungry get increasingly quiet and sleepy, till they seem content but way too skinny.

When Thomas was six days old, I met with a wonderful lactation consultant, Linda. I’ve worked with three IBCLCs over the years, each devoted and helpful, and I very much appreciate Linda’s wide range of experience: she is also a Registered Nurse and works in a hospital setting, both with regular maternity patients and with premature NICU babies, and works in a home setting (like me, a rather different kind of clientele). A hallmark of a good IBCLC (as I witnessed in mine) is affirming the mother at every interaction in specific ways: “You are such a good mother. You are caring for your baby. Your baby loves you.” A mother who desires to breastfeed and cannot is feeling so broken as a mother and she needs this encouragement.

At the IBCLC's visit, we used a transfer scale and learned that poor Thomas transferred only 4 mL on one side and 0 mL on the other side in 20 minutes. A typical feeding at his age of one week would be about 30 mL (one ounce), so he wasn't consuming nearly enough milk, nor was he signaling my body to make any milk.

Ultimately, we hired the lactation consultant to come to our home for two visits, plus I availed myself of her free follow-up advice many times via phone, text, and (primarily) email. We were still communicating at least weekly two months later.

I began exclusively pumping and bottle-feeding, using the paced bottle-feeding method, which makes the baby work harder and more closely mimics breastfeeding.

WEEK 2 (1 week old)

I began pumping with a hospital-grade pump eight times daily for 15 minutes each, including twice overnight. When pumping exclusively, only a hospital-grade pump will provide enough stimulation to maintain or create supply. A hospital-grade supply costs about $1,500 so a mother typically rents one from a local hospital's lactation department (ours rents them for $40/month).

When pumping, one wants to imitate a nursing newborn, who should be nursing well 10-12 times per 24 hours. It is important to pump about eight times per day, including at least right before bed, in the middle of the night, and right at waking, with no more than about a 4 hours' break during the night feedings. (It is best to consult with an IBCLC about this when establishing a milk supply than to rely on blog posts like this one.)

An exclusively pumping mama is really doing something similar (not equivalent) to feeding twins. She is "feeding the pump" about eight times daily plus feeding the baby 10-12 times daily, and she may be attempting to feed the baby by both breastfeeding and bottle-feeding at most or all of those sessions. I found the idea of "caring for twins" helped me psychologically because I was crushed under the duties of pumping and caring for my newborn: once I thought of them as twins, I realized that everybody knows caring for twins is crushing, so what I was doing was anticipated, in that sense.

My milk supply remained "in the tank" for a week more even though I was pumping around the clock, taking a galactogue, and drinking sufficient water. We eliminated the main three causes of milk failing to "come in"--blood loss at delivery, retained placenta, thyroid problems—and never did figure out what was going wrong.

I reached out to my former LLL community, where those wonderful ladies embraced me immediately. By the end of one day of emails and text messaging, a mother whom I'd never met agreed to donate frozen breast milk to Thomas, so my husband drove to pick it up. I was moved to tears by the generosity of Thomas' other "milk mommy" (who ended up donating to us a second batch later when we still needed more).

Thomas was 11 days old before my body made enough milk to match his requirements. That is actually a rather long time when one considers that, without supplementation, the newborn would have spent that time losing weight and crying a lot, or slowly sleeping more and more because he was undernourished.
Getting enough sucking with his pacifier

This week, I bought my baby a pacifier, which may seem standard to many American moms but wasn’t to me: I'd raised four babies without using a pacifier. However, this time around, I realized that babies need a lot of sucking for proper oral-muscular and neurological development and that an exclusively bottle-fed baby isn’t going to get enough hours of sucking from ten or so bottles per day. Thomas did not like to spend time at the breast because it was so frustrating and I decided, for his sake, he deserved a pacifier, which, it turns out, he loved.

WEEK 3 (2 weeks old)

Waiting for his frenectomy at two weeks old

Thomas' appointment for a frenectomy to surgically correct his tongue and lip tie were scheduled for a month out, but a patient cancellation let us get Thomas in for his frenectomy at two weeks old. Then, every four hours (including in the middle of the night) for the next two weeks, I had to stretch Thomas’ wounds so they wouldn’t reattach while healing (following these video instructions from our doctor).

At 15 days old, I was able to freeze extra milk for the first time!

At 20 days old, Thomas was able to transfer about half an ounce of milk before tiring out. I rented a transfer scale from the hospital: such a scale isn’t a standard scale to weigh a baby, but a more sensitive one that can measure exactly how many grams a baby gains in a feeding. (One gram = one milliliter, and 30 milliliters = one ounce.) When using a transfer scale, one weighs the baby in clothing and diaper ahead of time, then nurses immediately. If the baby poops during the feeding, don’t change the diaper; if the baby spits up during the feeding, don’t wipe it away but make sure the milk stays on the baby’s own clothing. After the feeding, weigh the baby in exactly the same clothing and diaper, then calculate the weight gain, which will equal how much milk the baby transferred from Mama. I find a transfer scale (which rents for $40 per week at our local hospital) an invaluable tool for getting a baby from bottle to breast.

My emotions were so dark during those weeks. When Thomas was exclusively bottle-fed, I tearfully asked my LC if he would ever know I was special as his mommy, or would I just be anyone who can feed him a bottle. I truly, sincerely felt that he wouldn't know me, and it was such a joy to me when, by about a month old, I could see that he stopped crying if I picked him up, but no one else: he knows me!

WEEK 4 (3 weeks old)

I took Thomas to two sessions of Cranial Sacral Therapy, one before his frenectomy and one after, having heard a lot of "buzz" around this new practice for the last few years. I tend to steer clear of things that seem to be "New Age" and/or that can't be proven in placebo-controlled, double-blind trials. Ultimately, I didn’t perceive any benefit from CST, but I have only two anecdotal experiences with it.

By three weeks old, Thomas could transfer one ounce of milk during his best nursing sessions before falling asleep from fatigue, which looks different than a baby being satisfied and “milk drunk.” This was an improvement, but he had a long way to go considering that his intake was an average 30 ounces per day and his bottle feedings were about 3 ounces each.

Around this time is when I bought a Medela Special Needs Feeder (SNF), formerly known as a Haberman feeder. It is an extremely useful bottle for rewarding even the weakest sucks (which is why it is used with babies who have challenges, such as Down Syndrome) and teaches oral muscle strength in order to learn to breastfeed. I used this excellent bottle, although not exclusively.

Ten pounds at three weeks old
I felt vulnerable during this time. One day we lost our power for many hours. Thank God, I had bought an electric converter to connect my Symphony pump to the car battery, as I had to pump in the car in our driveway that afternoon. Later, it was 9:30 at night and I was minutes away from having to go pump in the dark in the car and face doing that over the course of the night when our power came back on. Even if I had formula in the house, I couldn't have gone 12 hours without pumping without me getting sick with mastitis, and that created an alarming feeling.

It has been vulnerable to go out in public. I learned quickly that if I had used powdered formula, it wouldn't really spill nor did it require its own cooler and ice packs, but my containers of milk spilled a few times! And then I had no milk with which to feed my baby! I became very careful to seal everything tight and I'd take enough milk with me for three times as long as my outing required, just in case I spilled some.

WEEK 5 (4 weeks old)

Eleven pounds at four weeks old

Thomas continued transferring only one ounce and fatiguing easily. This was an emotionally dark time because I felt internal pressure to get back to a normal life caring for my other four children. I tried going back to Mass (too early), I tried resuming homeschooling the core curriculum, but meanwhile I was racing back to the pump so many times per day, leaving my children unsupervised, and trying not to lose my temper when they understandably got into mischief. If my baby had any hope of learning to breastfeed exclusively, I was willing to do this much work, but I felt no hope, so was this all a waste of my time and effort, and that of everyone supporting me?

WEEK 6 (5 weeks old)

At five weeks old, Thomas began being able to transfer two ounces on occasion! This was also the first time he began occasionally rejecting plastic (his bottle and his pacifier) for his real mommy, a milestone that remains utterly precious to me. I felt like Thomas was slowly falling in love with nursing.
Bittersweet that other people could feed my baby

This week was the first time I felt confident enough that Thomas could breastfeed enough quantity that I'd go out in public with only one 3-oz bottle's worth of milk just in case. And then he achieved the milestone of not needing that bottle when we went out! (It was two more weeks, though, that I still packed a bottle every time we went out, even though he didn’t use it, before I left that ‘security blanket’ at home.)

WEEK 7 (6 weeks old)

At six weeks old, Thomas was able to transfer three ounces! This was the milestone I was watching for because that meant Thomas could--at least sometimes--manage an entire feeding on his own strength.

Waking up to an empty bottle, never having used it overnight

I set my sights first on making nighttime easier: It had been brutally exhausting overnight to attempt nursing the baby, then prepare him bottles, then get him back to sleep, and then stay awake myself pumping, only to catch a few winks before the baby woke hungry again. All these weeks, I’d been getting by on three to five cumulative hours of sleep with wakings of one to two hours during the night, so making nighttime better was the first place I focused. I noticed at six weeks old that Thomas began to be satisfied increasingly by breastfeeding overnight and would fall back to sleep, and one night he needed only one bottle all night! Soon, I eliminated bottles from our overnight routine!

It was this week that I, for the first time--despite my lactation consultant’s encouragement and assurance this whole time--felt a glimmer of hope that Thomas would actually learn to be exclusively breastfed. Invigorated by new hope, I began tracking not just daily pumping but my bottle-feeding and my breastfeeding. I began watching numbers carefully to see if Thomas could take over maintaining my supply, which required I begin pumping a little bit less to see what he could do.

I began trying hard always to breastfeed Thomas first, then offer a bottle only if he were crying. I noticed that at those times he would take only one ounce by bottle, then spit the nipple out of his mouth: by following his lead instead of putting him on a schedule of how many ounces he would be given at what times, I knew he was just needing an occasional “topping off.” As soon as I began this effort, Thomas’ intake by bottle dropped to a cumulative eight ounces per day (over about eight bottles), which told me he was taking a good 20 ounces directly from Mama!

This article on “responsive bottle-feeding” is very interesting and instructive, in my opinion.

WEEK 8 (7 weeks old)

This week I learned that weaning down from pumping 40 ounces daily over 8 sessions to pumping 20 ounces daily over 4 sessions in just more than a week is really, really stupid, and my case of mastitis told me so.

On the bright side, I watched Thomas reduce from about eight “top-off” bottles per day to five of them, to three of them, to finally the grandest milestone of them all:

Bottles on the drying rack

At seven weeks and five days old, Thomas went an entire day without needing any supplementary bottles! And he hasn’t needed any in the days since!

Storing away all Thomas' bottles for if we ever need them for another baby,
but this baby doesn't need them!

WEEK 9 (8 weeks old)

8-week birthday and 13 pounds even!

At eight weeks old, I returned our rental scale to the hospital—a huge symbolic gesture for me because I no longer could rely on the scale to confirm that Thomas was nursing well and gaining weight. I gave up my 'security blanket.'

WEEK 10 (9 weeks old)

From birth, I had kept track of Thomas' weight on a scratch paper taped to my mirror. I knew that when bottle-fed, he was gaining at a certain rate and I watched him continue to gain at that same rate as he gradually gave up bottles. When I returned the scale, I took comfort in knowing that Thomas would go to a well-baby check one week later and I would know if he were continuing to gain well.

13 lbs 12 oz at 9 weeks

Indeed, in one week since returning the scale, Thomas gained 12 ounces! He's doing just fine and I truly feel confident for the first time in his nine weeks.

Thomas is now an exclusively breastfed baby. The next part of our journey is for me to wean down safely from pumping, which will take some more weeks.

Special thanks

When being certified as a La Leche League leader, one is taught that studies show that the most influential factor for whether breastfeeding will be successful or not is the degree of support the husband offers his wife. While a League Leader, I saw this truth exemplified again and again. Special thanks go to my husband Chris for his support during these two long months, without which I am certain Thomas would not be exclusively breastfeeding today. Chris ran the household entirely during my postpartum time, plus brought in the help of his parents and then my stepfather to stay with us so I wasn’t actually running the home myself until six weeks postpartum (and after that he still helps tremendously). Chris spent the necessary money on hiring the lactation consultant, renting the pump and scale, and buying accessory pump parts, all of which adds up. Chris did grocery shopping, cooking, cleaning, watching of our children, and driving to a strangers’ home to pick up her breast milk for me. Chris listened to my woes, dried my tears, and always encouraged me that getting Thomas successfully nursing was our family’s current top priority, and that it ranked above my cooking dinner or dressing the two-year-old in daytime clothing or homeschooling our third and first graders. If Chris hadn’t chosen to support me in these ways, my efforts would not have been enough, and for this I thank him.


  1. This is a great accomplishment, my friend. Congratulations on such an extraordinary success! It may not be viewed as such in the world's eyes, but this is womanly achievement at its finest ;)

  2. Great job, Katherine! Every blog post lately contains a lament that you are doing a terrible job as a mother of 5, and quite the opposite is true. Simply the fact that you have managed to get Thomas completely off the bottle in such a short time is a huge accomplishment! And if you are still pumping for a few weeks, that will take a lot of your time. Your most important job now is to feed Thomas, and if that means that you can't usually cook, it DOESN"T mean you're not succeeding as a mother. Be gentle with yourself; you're doing great. :-)

    I just sent this amazingly informative post to my daughter who is training to be a labor doula because it is so informative.