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PREVENTION OF SORE NIPPLES: To prevent sore nipples, ensure a large amount of areola enters baby’s mouth! Do not coat a thrush infected nipple with expressed milk for healing- it actually feeds the yeast and makes it worse. A simple rinse will do.
PROBIOTICS: You want the fancy “Women’s Health Probiotics” ; the one I like most is call Raw vaginal Care by Garden of Life. These are for the mother to take. THRUSH: TREATMENT OF Candida Infection NIPPLES will need the care of your OBGYN for APNO ointment for signs of Thrush. Wipe off excess. The following link is a sheet to print out for your Dr. http://www.breastfeedinginc.ca/content.php?pagename=doc-APNO but if that link is not working you can link my directions for healthcare providers for APNO found on my blog. This will have dosing directions but typically you apply a shin sheen over the nipple and areola each time after nursing. This means use a ½ pea sized amount and rub your fingers together until it disappears, then use it on your nipples. In this amount it is compatable with breastfeeding. If the APNO does not resolve the thrush alone: “Persistant Pain” Academy of Breastfeeding Medicine 2016, "Oral fluconazole (200 mg once, then 100 mg daily for 7–10 days) may be used for resistant cases. Before prescribing fluconazole, review all maternal medications and assess for drug interactions. Do not use fluconazole in combination with domperidone or erythromycin due to concern of prolonged QT intervals.” Evidence of Pediatric Thrush: If the Baby has a small amount of light white on the tongue that will not wipe off, Contact the Pediatrician so the infant and the mother get concurrent treatment and do not pass it back and forth. Remember the goal with oral nystatin is to paint the inside of the babies mouth, vs put it alongside one cheek just to be swallowed. Spread it around! LAUNDRY: when you have thrush will need Grapefruit seed extract and it into your wash to help kill candida on clothes. Dry on hot, or sun dry. Bleach if you need to. Be aware that anything that touches your breast may hold onto the spores, so separate the towels; you get your own. Boil things that go into your baby’s mouth or steam them in a sterilizer bag (Bottle nipples, chewwies, pacis, pump flanges) I think a steamer bag is easier than boiling everything. Please carefully reconsider the instructions from anyone to apply grapefruit seed extract to your nipple neat- it is a great way to chemically burn your nipple. NONE OF THAT WORKING? TRY GENTIAN VIOLET PER DR. NEWMAN: “We believe that gentian violet (combined with “all purpose nipple ointment”, see the information sheet Candida Protocol) is a good treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it often works even when used alone (though we don’t recommend this, see first paragraph), and relief is rapid. It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), but not skin. The baby's lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It’s easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%. 1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment. 2. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy. 3. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby’s cheeks and around his mouth. 4. Dip a clean ear swab (Q-tip) into the gentian violet. 5. Paint one of your nipples and the areola and let dry for a few seconds. 6. Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated. 7. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up that side. 8. Repeat for the other side 9. If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go. 10. A cotton pad can then be used to wipe the excess gentian violet from baby’s face 11. 11. Repeat the treatment each day for at least three or four days t see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida Protocol information sheet for how long to use gentian violet). 12. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days if necessary. 13. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet, or rinsed in a solution with grapefruit seed extract. Consider stopping artificial nipples. Artificial nipples can interfere with the way the baby latches on and may contribute to your pain. 14. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, only very occasionally seem to be bothered by thrush. 15. Uncommonly, babies who are treated with gentian violet develop sores in the mouth that may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding. 16. It is advisable that a mother with a recurring infection take probiotics orally for a few weeks and or grapefruit seed extract orally for at least 2 weeks. In this case, the baby should probably be treated with probiotics as well (see the Candida Protocol information sheet). If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of re-infection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. See the Candida Protocol information sheet. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Gentian Violet, Revised 2009 Written and Revised by Jack Newman, MD, FRCPC 1995-2005 Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2009 All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions.” Here is where to get it: https://www.walgreens.com/store/c/de-la-cruz-gentian-violet-first-aid-antiseptic-liquid/ID=prod1550372-product# The Thrush Plan:
Serena Meyer, RN, IBCLC, RLC
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 Preparing for Your Return to Work: The Breastfeeding Mother’s Guide
When a family is expecting a baby, it’s a time full of wonder and happy expectation. For months, a mother feels fluttering and quickening, the soft movements of her baby. For many families, it is also a time for making plans to welcome a new family member. Parents may also use the time of pregnancy or the waiting period for adoption to investigate how to support the breastfeeding relationship in the workplace or in school. This article addresses some common questions breastfeeding mothers have about preparing for a return to work and includes the concerns that mothers who do not have a pro-breastfeeding workplace or school may face. Talk to your employer This article, Pumping 9 to 5, provides some information on how to talk to your employer about breastfeeding and how to make a plan for expressing your milk at work. Being ready for this conversation, with an idea of what you will need in terms of space and time, will help make your points clear and concise. Take the time you need to make a plan before you speak with anyone at your school or job. Other workplaces, tribes, and many places of higher education have set up lactation rooms; think about bringing them up in your conversation to support your requests. It may also be important to mention the ways your workplace or school will benefit from setting up a lactation room for other families. This booklet explains some of the possible concerns that a business or institution may have about setting up a lactation program for individuals that either work in or attend the facility. Know your rights There are State and Federal Laws in place to support breastfeeding mothers. For example California Labor Code 1030-1033 stipulates: Every employer, including the state and any political subdivision, shall provide a reasonable amount of break time to accommodate an employee desiring to express breast milk for the employee's infant child. The break time shall, if possible, run concurrently with any break time already provided to the employee. Additionally, the IHS and many Government agencies provide pumping breaks for their employees, and many institutions already have supportive programs in place for breastfeeding mothers. The Affordable Care Act of 2010, states that: Effective March 23, 2010, the Patient Protection and Affordable Care Act amended the FLSA to require employers to provide a nursing mother reasonable break time to express breast milk after the birth of her child. The amendment also requires that employers provide a place for an employee to express breast milk. Consider all of your options Are you able to change your work schedule or delay returning to work or school? Some mothers have worked out job shares or found other ways to minimize separation from their babies. Talk to your employer about what might work for you.
When should I start expressing milk? Babies grow so fast! They are newborns for only a few weeks, and before you know it, they are smiling, cooing, and reaching for your face while you are nursing. In the first several weeks after birth, take all the time you can to relax, get to know your baby, and just enjoy being his mom. Unless you have to return to work right away, it is recommended that mothers wait until breastfeeding is well-established before they begin expressing milk for returning to work: for most mothers, somewhere between 3-4 weeks. If you have to return to work earlier than 4-6 weeks, you might wish to begin pumping milk two weeks before you plan to return to work. Learn how to express your milk Preparing for your return to work or school can begin with learning to express your milk.
How do I hand express? Hand expression requires no special equipment and can be an effective way for you to remove milk when separated from your baby. Some mothers find that hand expression is more effective for them than pumping because it is more comfortable, and they can feel for areas of fullness and apply pressure with their fingers exactly where it is needed. Once you have success with a method of hand expression, you may feel that you are able to meet your baby’s needs without a pump. What type of pump should I use? A high-quality, full-size, double-electric pump is recommended for a mom who plans to pump milk every day. A pump that is made by a manufacturer specializing in breastfeeding equipment will be of higher quality than cheaper pumps made by a company whose primary products are bottle-feeding equipment or baby food. A breast pump is an item for which the old adage, “You get what you pay for,” often rings true. Another option for many mothers is renting a multiple-user pump from a trusted source such as a Hospital, Tribal Health Clinic, or local IBCLC. Most WIC offices provide pumps to moms who are returning to work or school; contact your local WIC office to see if you qualify. Many families have health insurance that is willing to cover the cost of renting a hospital-grade pump. If you are able, call your insurance provider for the details of your own coverage when you are pregnant. Recent 2011 news from the IRS states that electric pumps are now tax deductible, so keep your receipts for your tax records. In our opinion, the top three single user pumps on the market today are: Pump Brand/Model Cost range Warranty Mechanics WHO-CODE Spectra S1 or S2 $115-250 2 year Closed system Compliant Hygeia Enjoye* $180-300 3 year Closed system Compliant Ameda Purely Yours $150-180 1 year Closed system Compliant Medela Pump in Style $250-350 1 year Open system Non-compliant *Sold in the category commonly referred to as single-user pumps; Hygeia is the only pump company that has sought and received FDA approval for their pump to be used by more than one person. What is the difference between an open and closed system pump?
What is the WHO CODE, and why is it important to consider when buying a breast pump? The “WHO CODE” is short for the World Health Organization’s International Code of the Marketing of Breastmilk Substitutes. Part of the purpose of the WHO CODE is to protect breastfeeding by preventing aggressive marketing of breastmilk substitutes and artificial nipples. Many people prefer to purchase a breast pump from a company that is supportive of and compliant with the WHO CODE. More information on both the breast pumps, the WHO CODE, and open and closed systems can be found at: The Problems with Medela How often should I express milk? Once a day is usually plenty at the beginning. Most moms find that they are able to express the most milk in the morning hours. You can nurse your baby on one side while expressing milk on the other side. Or you could pump both sides about one hour after your baby’s first morning feeding. Don’t worry if you don’t get very much milk at first. It takes practice, and your body needs to “learn” to make milk for that extra “feeding.” When milk is removed, your body responds by making more milk at a faster rate. It can take a few days for your body to increase production (Daly, Kent, Owens et al.,1996). Any milk collected during these practice sessions can be stored in the freezer. How much milk should I have stored in my freezer? Many mothers find that they feel less stress if they to know that they don't need to create a large freezer stash of milk before they return to work. Instead, they can use their maternity leave to focus on being with their babies and getting breastfeeding well-established. If you have enough milk to send with your baby on your first day, then you have enough in the freezer. It is important to express as much milk while you are at work as your baby needs during that time. If your baby needs 10 ounces while you are away at work, then you need to pump at least 10 ounces each day. For example: If you were to only pump 8 ounces and send 2 ounces from the freezer each day, you would not be expressing the amount of milk your baby requires. Your body will “think” that your baby needs 2 fewer ounces each day than he really does, and your production will not match his demand. If you start to run out of milk in your freezer, you may face the difficult decision of how to meet your baby’s needs. Many mothers learn too late that increasing their milk supply to meet their baby’s demands is more complex than it seems. Meeting your child’s daily needs for expressed milk during separation is the best way to avoid difficulties later. Using the simple system described, you pump each day what your baby would need the next day. This way you only use the small freezer stash for emergencies, such as dropping and spilling a day’s worth of milk, or other milk-related calamities. If you need information about returning to work or expressing your milk, a Breastfeeding Counselor , La Leche League Leader, Nursing Mother’s Counsel or International Board Certified Lactation Consultant may be able to help. Accessing a community support system can help you reach your breastfeeding goals. You may also be interested in these articles: Returning to Work: The Breastfeeding Mother’s Guide Are There Differences Between Breastfeeding Directly and Bottle-Feeding Expressed Milk? Breast versus Bottle: How Much Should Baby Take? Facts Every Employed Breastfeeding Mother Needs to Know I’m Worried My Milk supply is Drying Up, What Can I Do? References Black Bear, J. (2011). Breastmilk Storage and Handling Guidelines. http://nativemothering.com/2011/04/breastmilk-storage-guidelines/ Daly, S., Kent, J., Owens, R. & Hartmann, P. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiol, 81(5), 861-75. Easy Steps to Supporting Breastfeeding Employees. (2008). U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau. Produced in contract with Every Mother, Inc. and Rich Winter Design and Multimedia. http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/easysteps.pdf Forbes, B. (2011). What is the WHO-CODE? Website: http://www.bestforbabes.org/what-is-the-who-code Internal Revenue Bulletin. Lactation Expenses as Medical Expenses. (2011). Website: http://www.irs.gov/irb/2011-09_IRB/ar11.html Jones E., Dimmock, P. W. & Spencer, S. A. ( 2001). A Randomised Controlled Trial to Compare Methods of Milk Expression After Preterm Delivery. Arch Dis Child Fetal Neonatal Ed, 85, F91–F95 Meier, P. Engstrom, J. Janes, J. Jegier, B. & Loera, F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32, 103-110 Morton J., Hall, J., Wong, R., Thairu, L., Benitz, W. & Rhine, W. (2009) Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology, advance online publication,29, 757-764 Shebala, M. (2012, January 26). Benefits of breastfeeding in workplaces touted. Navajo Times, http://www.navajotimes.com/opinions/2012/0112/012612notebook.php Silver, B. (2010). College and University Lactation Programs, some Additional Considerations. The Elsevier Foundation, University of Rhode Island Schmidt Labor Research Center.http://www.uri.edu/worklife/family/family%20pics-docs/LactationPrograms%20FINAL.pdf Simmance, A. (2011). Why You Shouldn't Buy, Sell, or Borrow a Second Hand Medela Swing Pump. Website: http://mythnomore.blogspot.com/2011/08/why-you-shouldnt-buy-sell-or-borrow.html State of California, California Labor Code § 1030. 2002: Chapter 3.8, Section 1030, Part 3 of Division 2 of the Labor Code http://www.google.com/url?q=http%3A%2F%2Fwww.cdph.ca.gov%2FHealthInfo%2Fhealthyliving%2Fchildfamily%2FPages%2FCaliforniaLawsRelatedtoBreastfeeding.aspx%23workingandbreastfeeding&sa=D&sntz=1&usg=AFQjCNHUWIwkLISI2im9IiolxL9ZB-IVhA West, A. (2011). The Problems with Medela. Website: http://www.justwestofcrunchy.com/2011/01/19/the-problems-with-medela/ © 2012 Serena Meyer, IBCLC and Teglene Ryan OVERSUPPLY PROTOCOL #2
TO REDUCE SUPPLY HOW IT WORKS: Oftentimes the milk supply has been driven up by early pumping. We feel that our breast is full, so we pump. This tells the body that more milk is required. Slowly milk production circles up. Infants become gassy, often stool color changes to green, sometimes it will contain foam, blood or mucous. They either gain weight very fast, or resist feeding at the breast- coughing, gulping, and sputtering during letdowns of milk. In milk there is a small protein called the Feedback Inhibitor of Lactation. As the milk builds up there is more FIL; this slows down production. So an empty breast milk has less FIL and makes milk faster and a full breast produces milk slower. The goal with reducing supply is to stay full but not painfully engorged. For more serious situations sometimes I wait and try to start reducing supply with an antibiotic on board to offset the likelihood of full blown mastitis. These are rare situations and require teamwork between the IBCLC and MD. BLOCK FEEDING: Block feeding is when you feed for a specific amount of time on one breast, or you pick a certain amount of feedings on one side. I start blocks, at 1 feeding per side . Some individuals need to work up to 4 feedings or about 8 hours on one side. Start slowly and allow your body to adjust. If your supply is very big you need to go slowly. You can pump briefly/nurse for 4 minutes for comfort but don’t fully drain the unused breast between blocks. Think about 1 oz. If we use the Sudafed you will need to use the type behind the counter. You can talk to your Dr to make sure there is no issue with this medication - but typically it is compatable with breastfeeding. the side effect is that it can reduce supply about 20% ( see this study here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884328/ ) Take 120 mgs of Sudafed extended release in the morning the first day and we’ll plan on taking it for a few weeks. We will taper the dose down gradually. Day 1: 120mg Day2: 120mg Day3: 120mg Day4: 60mg ( let me know how it’s going) Day 5: 60mg Day 6: 60mg Lecithin: The typical dose for treatment for plugged ducts is 3600-4800 mg . I start the dose at 4800mg once daily for prophylactic treatment for blocked ducts. Happy Ducts Tincture: preventative treatment for mastitis. PREVENTING/RELIEVING ENGORGEMENT: Encourage baby to breastfeed every 2-3 hours to remove milk from the breast. If engorgement occurs, fill a tub with warm water and soak breasts or heat a wet towel (or dry socks filled with rice) in microwave and place on breasts prior to feeding to help soften, allow baby to breastfeed to remove milk. After nursing try something cool versus hot to reduce inflammation. So, before nursing is warm compresses, after is cool. Ibuprofen: 600mg every 8 hours for the first few days with longer blocks to reduce inflammation and swelling from engorgement. **Birth Control: The Minipill is ok for regular breastfeeding mothers. If we really need to reduce your supply and it resists normal treatment we can go on regular birth control pills because Estrogen reduces milk production. This is a last resort and you’d really want to talk that over with your Dr first. Don’t start this without talking to your LC first! Can’t sleep at all because of the Sudafed? Benedryl is ok to take in the evening up to 25mg, but watch for sedation in you, not necessarily for your baby. Co-sleeping with Benedryl is not a good idea. If you take it, start with a pediatric dose for yourself which is 12.5mg. As always please make sure any over the counter medications are compatible for your own health conditions. TEA: Lots of peppermint tea, make a large batch! Helps to tame a wild supply! Altoids are good too. ESSENTIAL OIL if all else fails to lower supply: For reducing your supply we are going to make a special combination of 15 ml of carrier oil to 1 drop cleary sage plus 1 drop peppermint. This should be applied topically to the armpits twice a day liberally, and then blotted off after about ten minutes of massage. Massage the whole breast, up to the armpit 3x a day for 5 days. So everything minus the actual nipple. Sage tincture: May help reduce oversupply. There is a new study coming out but it’s not yet published on aerophasia induced reflux. This is basically a long way to say that if you chug down enough air you are going to burp a bunch of your meal back out. The solution, while simple, takes a few weeks while we get your supply back under control. The Oversupply Plan: 1.) block feeding 2 feeds per breast 2.) add in morning Sudafed (once a day) 3.) feed uphill, and burp baby 4.) take lecithin 4800 mg, 1x a day ( to prevent blocks) 5.) take 300mg of magnesium 1x a day ( for oald) working up toward 600mg The Reflux Plan: 1.) Burp way more 2.) Uphill nursing 3.) Block feeding 4.) Reduce maternal oversupply 5.) Burp baby with less tummy pressure 6.) Log roll for diaper changes 7.) Trial of paci for 15 mins post feeding as you can, the additional swallowing may help down food 8.) Keep baby upright 15 minutes after daytime feedings Lets talk more about the "stomach flu" better known as the Norwalk virus, which is the prototype strain of human caliciviruses named for the first town the epidemic was noted in, in 1972. It has a beautiful structure seen here:http://www.ncbi.nlm.nih.gov/pubmed/16641296. The are not exactly sure how it replicates according to a study done in 2002, it fails to grow on cell substrate in labs.
Believe it or not, people voluntarily infected themselves at Baylor College of Medicine so that it's viral shedding duration through feces could be documented (2008). In case you thought those first 2 days were the period of highest infection risk, you're probably right but "Virus shedding was first detected by antigen ELISA approximately 33 hours (median 42 hours) after inoculation and lasted 10 days (median 7 days) after inoculation."http://www.ncbi.nlm.nih.gov/pubmed/18826818 In other words, please don't go getting all relaxed about it, there is some documentation that shedding begins as early as the incubation period ( about 10-60 hours before you get sick). It generally lasts about 24-48 hours, and you can communicate the disease actively for 48 hours after resolution. So how do you get rid of it when you need 2 parts/mil to get sick? Well good luck with that. You can use a steam cleaner, but the norwalk virus survives regular temps of heating to 60ºC for 30 minutes, so it has to be a real steam cleaner. According to Public Health Saftey of Canada, (data sheets available here: http://www.phac-aspc.gc.ca/lab…/…/psds-ftss/msds112e-eng.php) you come up with this: "SUSCEPTIBILITY TO DISINFECTANTS: Susceptible to 1% sodium hypochlorite, 2% glutaraldehyde" That's it folks. So now you know what kills it, you're not sure how to get that dilution. If you are starting with 5% household bleach, you dilute 1 part bleach to 4 equal parts clean water. Hope this clears up some of the conversation I've had with multiple sick folks! Todays PSA. Did you know that your milk is amazing and fights cancer? Read up on HAMLET. This is also part of the reason why many adults with GI/Esophageal cancer are receiving human milk as part of their treatment. It's a protein that not only demolishes cancer, but now is also being used to help disable MRSA. Full article here: http://www.healthline.com/health-news/children-breast-milk-protein-kills-superbugs-050213
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