Dr. Ruth Lawrence, professor, author and researcher, serves on Breastfeeding.com's medical advisory board.  Dr. Lawrence is a professor of pediatrics, obstetrics and gynecology at the University of Rochester.  She is also director of the university's Breastfeeding and Human Lactation Study Center.  Dr. Lawrence has answered many of your questions on pumping and storing breastmilk.  Look for more of Dr. Lawrence's answers to your questions next week!

Dr. Lawrence is the author of "Breastfeeding: A Guide for the Medical Profession," the standard medical reference book for breastfeeding.  She was one of eight doctors who helped the American Academy of Pediatrics draft its 1997 policy statement supporting breastfeeding.

	Can I mix milk from different pumping sessions?
	Do I have a let down problem or a supply problem?
	Is not cleaning my pump between sessions dangerous?
	What type of pump is best?
	Should I add cereal to my daughter's bottles?

Can I mix milk from different pumping sessions?

I returned to work last week and have been pumping and storing milk.  I have a couple of questions.  First, can I add milk from a current pumping session into an amount that was collected earlier and already cooled?

Second, I don't think Theo is eating enough while I am away. For example, last week he was with his caregiver for 7 hours and he would only take 6 oz of milk and 1/4 of a small avocado. When I arrived home he was starving and nursed on and off all evening.  This pattern continued all week.  How can I be sure he is getting enough to eat? 





To answer your first question, the important point here is the time interval. We are very concerned about what we call layering - collecting a little bit, then a little bit more, and opening the container multiple times.  Every time you open the container you introduce an opportunity for contamination. If, however, it is within the same day and the milk is well cooled, it should be OK.  We are more concerned when you add fresh milk to frozen milk.  This partially thaws the frozen milk and freezing and thawing does affect the quality of the milk. 

Regarding your second question...  I would presume you probably fed him just before leaving him with a caregiver.  It is helpful also to feed your baby right when you pick him up.  With respect to a small amount of avocado as solid food, what many mothers decide to do is have the solids given when the baby is with the caregiver, since only you can nurse your baby. Ultimately, it may be that your baby will take more solids when at the caregiver and then nurse more with you.  It is very normal for Theo not to take as many fluids when he is at daycare, but also remember that this may change over time.  Give it another week to see if he increases his fluid intake as he gets used to the bottle.  As long as you are convinced that your caregiver is making every reasonable effort to feed your baby, you shouldn't worry.  He may just decide to wait for you to nurse.  From a nutritional standpoint, as long as he makes up by nursing more when you are with him in the morning and evening, this is probably okay.

As babies get older in daycare they tend to do what other kids are doing.  When other kids are eating, he will probably learn to eat too.  So, the situation will likely improve over time.

Do I have a let down problem or a supply problem?

I started back to work when my son was 6 weeks old and have never been able to get more than 2 oz. total when pumping at work (with the exception of the wonderful 2 weeks my doctor put me on Reglan when I could get 6 oz. per session).  My son seems satisfied when he nurses and is gaining weight (8lbs 11oz at birth to 15lbs 12 oz at 4mo. checkup), but after pumping every 2 hours at work (4 times a day) I only take home about 5-6 ounces. Even when I pump and nurse simultaneously I don't get more than 1 oz. I have taken all the herbs, drink lots of water, use a electric double pump (the Nurture II from Bailey).

Does this sound like a let-down problem or a supply problem? Should I try using a different pump (the Nurture II is self- regulated and takes about 3 seconds to get up to the right pressure, and my son is a VERY aggressive eater)  Please help!  I am also curious as to why my OB will only prescribe Reglan for 2 weeks, when I've heard of women taking it the entire time they breastfeed!





Your question is about pumping and the volume being pumped.  We are concerned that people take all sorts of medications and the herbs taken have potent ingredients.  This is not always good.

You ask about letdown versus supply.  The only way to really know is to use a bit of oxytocin before you pump.  This must be prescribed by a physician.  The product that used to be available specifically for letdown problems is no longer made.  The physician must ask the pharmacist to take the injectable form of oxytocin from the ampoule into a container for nose drops.  This has to be taken nasally, because the strength of the injectable is about 1/4 the strength of the nasal version.  Mom must put 4 drops in one nostril immediately before (1-2 minutes) she pumps. So have the pump ready.  The expected effect would be significant letdown of milk.  If you don't experience this letdown, it is most likely that you have a supply problem.  On the other hand, you comment that you pump every two hours.  Your baby is 4 months old, usually by this age babies don't eat every 2 hours.  You may do better to stretch out the pumping sessions a bit - maybe to every 4 hours - to see if you get more milk this way.  Usually, when you leave your baby, you probably feed right before you leave and right when you get home.  The hassle of pumping so often (4 times) could be hampering your success.

I am not familiar with the pump that you have, so I'm not sure how efficient it is.  If it is not a double pump, you may need to take another dose of oxytocin for the other side.  If this pump is not electric, you need to get a good electric pump.  The brands I recommend are White River, Medela and Egnell.  Most mothers do best if they pump both breasts simultaneously.

About Reglan, your doctor is right, you don't want to take it indefinitely.  The usually time is two weeks.  Sometimes we give a second course of therapy.  In this case, where you have a healthy baby, it would be better to try other measures and avoid a potent drug like Reglan.

If the oxytocin helps and you find that it is a letdown problem, this is probably related to pumping. Usually, after taking the oxytocin for a few days, you don't need it anymore.  Mother Nature gets the idea.  It is typically a pump issue and not a nursing issue - mothers have difficulty pumping but they do beautifully with their baby.

If oxytocin doesn't help, then you probably should try another pump.  I would suggest you go to one of the ones we know well (listed above).  Just because a pump is electric, it doesn't necessarily mean that it is a good one.  Also, follow earlier comment about not pumping quite so often.

Is not cleaning my pump between sessions dangerous?

I can't always make the time to clean my pump in between pumping sessions (my company is very rigid about 15 minute breaks).  What kind of health risks does this pose?





This is a real problem. Perhaps the best solution would be for you to have more than one set of equipment.  So, when you go to pump the second time, you could use the second set of equipment.  That way, you could clean everything at the end of the day when your job is over. While human milk has a lot of protective qualities, nonetheless, it is important to take precautions to keep it bacteria free.

How many times per day you are pumping?  How long are your shifts?  If you work 8 hours at a time, pumping twice is probably adequate.  And then having two setups would work.

Most pump equipment should be rinsed out with clean water and stored where it could dry.  A cleansing solution provided by the pump company should be okay, but regular soap can give the baby diarrhea.  Be sure to clean the area well where the milk comes in contact - mainly the collecting bottle, which you fill, cap, and refrigerate.  Be sure to wash your hands before pumping, too!  At the end of the week, you should bring your equipment home and wash it thoroughly, preferably in the dishwasher.  Here, you have a non-sudsing detergent, so it is OK, and the high temperatures reached in the dishwasher are important.

What type of pump is best?

I am not returning to work, but I have a question about pumping.  I have tried to pump before so I can get Mazzie used to the bottle, but I hardly get anything when I pump.  I have an Avent Isis breast pump, do I need a better pump? 





I think the pump you are using is a hand pump.  If this is the case, you may have problem getting adequate milk. On the other hand, some women can adequately express large volumes of milk by hand, without any equipment at all!  However, if you seriously need to pump and collect milk, you should invest in a good pump.

An important part of the pump is the flange - the part that looks like a funnel and comes in contact with the breast.  Different brands of pumps have different styles of flanges.  Most of them are rigid, so the problems of changing pressure with the pump draws the breast into the flange. The soft silastin (made of silicone) pliable plastic flange is very different.  This is what we make heart valves and other artificial tissue pieces out of.  This type of flange allows the pump to create more of a milking action. Mothers who have problems with other pumps ought to think of getting a pump with a silastin flange.  The brand that holds the patent on a silastin flange is White River.  As far as electric pumps with a rigid flange, I would recommend Medela and Egnell, manufactured by Hollister.

Again, some women can pump more easily than others.  You really need to set yourself up to pump.  Make sure that you are relaxed and comfortable.  You need to give yourself the opportunity to letdown.  Before you apply any pump, gently stroke the breast, massage the breast, initiate letdown, and then apply this mechanical device. Playing soft music doesn't hurt, either.

Should I add cereal to my daughter's bottles?

My darling daughter is drinking 4, 3 oz bottles from 7:30 a.m.-6:30 p.m. (hours at the sitters).  My question is: is that enough for her, or should I try cereal in those 4 bottles?





I would think that she might be a little hungry on this amount.  We like babies to be exclusively breastfed for about six months, but five months should be fine to start cereal. I wouldn't put it in a bottle, though. This should be an eating, social experience.  Eating is a social experience throughout our lives, so you should let the sitter give her cereal once when you are away, then work up to 2-3 solid feeding each day during this time. Eventually, you will introduced other foods.  You should breastfeed the baby right before you leave, and when you return.

The ideal for cereal is to mix it with a bit of breastmilk and let your daughter try feeding it with a spoon, so that she learns to take solids.  Putting it in the bottle at this age is not the best way to go.  The first feeding a baby takes from a spoon is not going to be the best feeding ever. So, the sitter should begin with about a teaspoon of cereal mixed with milk. this is a learning event and developmental step for your daughter.  She may not know what to do with the cereal right away, but she will learn over time.



 

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