Ina May's Guide to Breastfeeding

8
If You Have a Job Outside Your Home

About sixty percent of U.S. mothers who have babies or young children are now employed outside their homes. No one knows how many of these children are nourished by their mothers’ milk, but we do know that only about a quarter of U.S. employers reported having any kind of “lactation program” for their employees in 2007. The good news is that even if you need to return to your job just a few weeks after giving birth, it may be possible for you to coordinate it with nursing your baby. Many women mistakenly assume that it will be so difficult to continue nursing once their maternity leave is up that they either decide against nursing at all or give it up during the first week or so. I’m not saying that this transition is easy, but lots of moms who have outside jobs and are committed to breastfeeding have demonstrated that it can be done. The secret to success for many of these women lies in their planning and preparation while still pregnant. Hopefully, you will have at least six weeks after giving birth before you return to the workplace, as it sometimes takes about four weeks for your milk supply to become well established.

In order to keep breastfeeding after you return to work, you must gain some measure of cooperation from your boss. It’s wise to draw up a written proposal, as putting your needs into written form will allow you to present all of the necessary facts without being interrupted.

What Should Be in the Proposal

Would you like to work part-time for a couple of months or do some of your work at your workplace and part of it from your home? If so, you will have to be the one to write up the new job description for yourself, defining where and how many hours you propose to work and outlining what your responsibilities will be. Be careful not to set yourself up for stress or failure by creating expectations that you may not be able to fulfill. Know, for instance, that you are not going to be able to do a full-time job in part-time hours. Be creative: If you are now working full-time and want to switch to part-time work, maybe you can find another employee who might job-share with you. If you want, you can build in to your proposal that there will be a trial period, after which you and your employer can assess how the arrangement is working out. If there is no chance of transferring all or part of your paid work to your home, look for any available space at your workplace that might be converted with little expense into a lactation room. Take into account your employer’s possible worries that your needs might be too expensive or complicated to accommodate, or offer easy ways for them to provide you with what you want and need. The following lists should give you some basic guidelines of what to ask for.

    What You’ll Need (at Least):

·   Permission to pump at work.

·   Break time during your workday.

·   Privacy (a curtain, if not a door).

·   A place to sit.

·   An electrical outlet.

    What You’d Like:

·   A door with an inside lock.

·   A sink with hot and cold running water.

·   A refrigerator.

·   A clean, pleasant room near your workstation.

·   A comfortable chair, preferably one with arms.

·   Flexible break time.

·   A written policy that supports the right of nursing employees to pump in the workplace and forbids other employees from harassing or discriminating against nursing mothers.

A 2000 report found that seventy-five percent of women who participated in two corporate lactation-support programs nursed their babies for at least six months. If you work for a company that is among the seventy-five percent without a lactation support program, you should start writing your proposal early. Gather evidence on the benefits of such a program to both employer and employees, so you can present it to your employer. Many employers are simply unaware of the needs of mothers who nurse their babies, as well as of the benefits that come from the creation of an environment that facilitates workplace pumping. Your job, then, is to educate. Point out studies of existing workplace programs that provide appropriate support for lactating employees; these will demonstrate that such programs save employers money in increased productivity and decreased absenteeism because of illness.1–2 Don’t forget to mention a recent study that showed that if all four-month-old babies were fully breastfed, fifty-six percent of hospital admissions of babies this age would be avoided.3 With numbers like these, you can point out that making it possible for more employees to breastfeed their babies is a good investment, one that is bound to lower the health-care costs borne by your employer.

Make sure that you are informed about your legal rights. Unfortunately, the United States still has no federal law to establish or protect a right to pump mother’s milk in the workplace. However, legislation in this area continues to be passed, because of the activism of nursing mothers. Approximately one-third of the states have laws concerning employees’ right to pump milk in the workplace, but these laws vary widely as to what they require of employers. Some—such as those in California, Connecticut, Hawaii, Illinois, Minnesota, Mississippi, Montana, New Mexico, New York, Oregon, Rhode Island, and Tennessee—require that an employer must allow pumping during breaks and/or provide a place to pump. Some other states use the word may instead of shall or must in their laws, which means there is no obligation on the part of the employer to provide what the law suggests would be nice. In any case, few states have laws providing for penalties for those companies that fail to follow the law; California, Hawaii, and Oregon are examples of states that do.

If you live in a state with a weak law regarding workplace pumping, keep in mind that even a law that doesn’t require compliance can be helpful, because it establishes a guideline to employers as to what a nursing employee needs. For instance, if your state’s law says that any space provided should not be a bathroom stall, that the space should be private or close to your work area, these provisions should be brought up in your negotiations with your employer.

Be aware of any other pregnant or lactating employees who might join in your quest for employer support for your pumping and storage needs—your employer might be less hesitant to help if you will not be the only person to benefit from a lactation program. It’s worthwhile to find out if any of the mothers of older children who nursed them did secret pumping in a toilet stall. If so, these mothers might become useful allies.

Present your written proposal to the person at your company in the best position to provide the support you need. If you work at a fairly large company, there may be a human-resources department that is responsible for flexible work schedules, family leave, on-site day care, and family-friendly benefits. Keep in mind that many women, depending upon the job they have, are able to continue working as they pump, especially when they use a hands-free pumping bra. Given the right setup and a little practice, pumping can be combined with answering emails, making phone calls, or typing.

You can find some very useful resources on the Internet to help you with drafting your proposal to educate your employer. Look, for instance, at a United States Breastfeeding Committee report, “Workplace Breastfeeding Support.”4 You can find documentation there that ear infections, which keep mothers away from work on average one to two days per year, can be reduced by two-thirds to three-fourths by nursing the child or that an average of $400 per baby is saved for your employer over the first year. Look also at the pamphlet from “The Business Case for Breastfeeding, Steps for Creating a Breast feeding Friendly Worksite: For Business Managers.” It focuses on a company’s potential return on investment in the areas of health insurance, absenteeism, productivity, and employee loyalty.5

Whatever your situation, even if you are the only employee at your workplace who is using a pumping station, please know that you are not alone. All over the country, there are women like yourself leaning toward their breast pumps, doing their best to get those last few drops bottled up. To combat your loneliness, it may help to join one of the online forums for pumping mothers. Trywww.pumpingmoms.orgwww.milkmemos.com, or www.workandpump.com. Checking out these sites while you are still pregnant will help you to better prepare for what is to come.

Returning to Your Job

I recommend that you plan, if possible, to return to work on a Wednesday or Thursday, rather than at the beginning of the week. This will give you the weekend to rework your plans, if you have a meltdown on your first day or two back on the job. Don’t be surprised if you feel emotional as you approach the time when you must return to work. This is to be expected, as it is hard to anticipate how you are going to feel juggling your job, your breast pump, bottles, your child-care arrangements, and the reactions of your coworkers to your new status as lactating mother.

Some new mothers make the mistake of thinking that they should practice pumping and getting their babies used to drinking from a bottle before they return to work. I would advise against giving your baby a bottle during the first weeks after birth, because you will still be establishing your milk supply during this period. For most women, this means that your breasts will need as much stimulation as possible. Once your milk supply is well established at around four weeks, you can begin to try out your breast pump and to start storing some expressed milk in your freezer. It’s a good idea to have about a week’s supply of milk stashed there before you return to work.

Breast-Pump Basics

You will need to rent (hospital-grade pumps are rentable and designed to be safe for multiple users, unlike those designed for the consumer market) or buy a good breast pump if you have a job that you must resume while you are breastfeeding. You may need both a good electric model and a manual model if you are going to be traveling without your baby.

As mentioned above, electric breast pumps are considered to be single-user products, so it’s better not to buy a used pump on eBay, share your pump with someone else, or sell yours when you finish using it. Milk can theoretically travel up the tubing and into the motor, which is impossible to clean. If your budget is too tight to consider buying what you think you need, check with your local WIC (Women, Infants, and Children) office, where they supply low-income women who are working or in school with pumps at a lower cost or sometimes free of charge.

“Loving Support Makes Breastfeeding Work” is the WIC breastfeeding-promotion campaign, which is national in scope and being implemented at the state-agency level. The goals of the campaign are to: encourage WIC participants to initiate and continue breastfeeding; increase referrals to WIC for breastfeeding support; increase general public acceptance and support of breastfeeding; and provide technical assistance to WIC state and local agency professionals in the promotion of breastfeeding. Visit the campaign’s website at: http://www.fns.usda.gov/wic/Breastfeeding/lovingsupport.HTM.

You may not want to buy a pump until your breastfeeding gets off to a good start, as pumps are not returnable. Be sure to check out the facilities you’ll have available for pumping before you decide which pump to buy.

Manual Pumps

Some manual pumps work by creating suction in a way similar to when the plunger of a syringe is pulled back on a vial of medication. These models feature a cylinder within another cylinder, with a rubber gasket sealing the space between them. The milk can be collected into the outer cylinder itself or into a separate bottle. Examples include the Kaneson Comfort Plus pump, the Lansinoh Easy Express, the cylinder hand breast pump, the Medela Spring Express or the Medela Manualectric, and the White River breast pump kit model 500.

Another type of manual pump is the hand-squeeze type. This kind allows you to squeeze the handle at the rate that works best for you, which may vary during a session (usually quickly in the beginning to stimulate letdown and then more slowly once your milk begins to flow). Examples include the Avent Isis, the Ameda one-hand breast pump, and the Medela Harmony.

Electric Pumps

The basic types of electric pumps are the battery-operated, the semi-automatic, and the fully automatic. Fully automatic or self-cycling electric pumps are generally the best choice for a woman who will be away from her baby for several hours a day on a regular basis or one who wants the machine to help build up her milk supply. The best models can be used to pump from both breasts simultaneously (cutting pumping time in half and increasing the amount of stimulation of your breasts). They also generate a suction and release pattern automatically, so you don’t have to control this manually. The pumps that can provide forty to sixty such cycles per minute most closely mimic the sucking pattern of a nursing baby. These are the most expensive of the portable models, but they still cost about one-fourth to one-third of a year’s worth of infant formula. You may find as much as a $100 difference between the top-grade model, which has a two-phase expression that mimics a nursing baby’s rhythm and allows you to adjust the speed, and the next-grade model, which lacks both of these features. The more expensive pumps allow for faster pumping (six to eight minutes) than the less fancy pumps (ten to twelve minutes). Examples of top-of-the-line pumps are any of the Medela Pump In Style line and the Ameda (Hollister) Purely Yours line (also marketed under the name Lansinoh) and the Avent Isis IQ Duo. Another pump in this category is Medela’s newest Freestyle pump—a very small, battery-powered double pump that uses the newest computer-generated suck rhythms.

An inexpensive electric pump is not recommended, due to its weaker motor. It may be painful, since slow cycling tends to pull on tender breast tissue. Additionally, the slower speed will not give adequate stimulation to the breast, so your milk production is not likely to be impressive.

Automatic electric pumps often come with a battery-pack option and an adapter that plugs into the cigarette lighter of your car. When plugging your pump into the wall socket, you will need a three-pronged outlet or plug adapter.

Breast-pump flanges

As a rule, it’s better to buy a pump that has flanges made of soft silicone rather than a harder material. The advantage of buying a pump from either Medela or Ameda is that they offer additional sizes in their flanges, with larger nipple tunnels for women who need them. The average size is 24mm. The soft silicone petal massaging inserts further reduce that size. Approximately forty percent of mothers need a larger-sized flange to pump in comfort, due to either nipple size or breast elasticity.

The Basics of Pumping

Practicing good hygiene is very important in pumping and storing your milk. Dried milk left on your breast shields or any of your pump parts can be a medium for bacterial growth, which could infect you or your baby. Wash your hands with soap and hot water each time before handling the breast shields and the pump. You’ll need to sterilize your pump or the pump collection kit before its first use if it is not already sterilized. The instruction manual that comes with your pump will explain what is necessary for your particular pump. You do not have to resterilize the pump parts, unless you are pumping for a baby in the NICU. If you are pumping multiple times in a day, studies have shown that, due to special live properties in human milk, it’s not necessary to wash the parts of your pump each time. Once every eight to ten hours is sufficient. Washing your pump parts when you return home will save you time at work.

Learning how to pump effectively takes practice, just as nursing itself often does, so please don’t give up if you don’t get much milk into your collection bottle during the first few sessions. It may take weeks for you to learn how to effectively empty both breasts. It’s useful for you to know that pumps collect only milk that you have let down. As you might guess from my earlier discussion of the letdown reflex, there are several things that you can do to help the right hormones reach sufficient levels for a good letdown and milk flow. First, make sure that you have a quiet, private place where you can pump comfortably. You’ll tend to have more milk early in the morning than later in the day, so try to fit in a pumping session then. Do your best not to focus on how much milk is being released, since caring too much will actually inhibit the flow of milk—when you take your mind off being anxious about the quantity of milk you are releasing, your pituitary will be better able to release the oxytocin that will stimulate your letdown reflex. You may want to try some calming activities; for example, it may help to look at a photo of your baby, smell an item of his clothing, or even sit at your computer and visit a breastfeeding chat area, where you can communicate with someone else who is doing what you are doing. Breathe deeply and slowly as you pump. Rituals are important for many moms, such as pumping in the same place at the same time while listening to the same music. It can also be helpful if you massage both breasts before you begin. If you find that you’re still having trouble stimulating your letdown, try leaning forward and using a comb to stroke your breast from chest to areola just before you pump. This tactic may sound odd, but it has worked well for some moms. You may also want to try applying a warm compress to your breast before pumping (though not if your breasts are engorged).

Most mothers need to pump for ten to fifteen minutes, with those last minutes achieving another letdown and resulting in the collection of extra milk. If you want to increase your milk supply, try massaging, then pumping for several minutes, massaging again, then pumping again. Remember that the more often you pump now, the more milk you will have later.

You must be well hydrated to do well at pumping. Make sure that you have plenty of water within reach while you are away from your baby and especially while you are pumping. One of the best ways to gauge whether you are drinking enough is to notice the color of your pee, which should be very light yellow.

Many women find that a hands-free bustier makes pumping far easier. Worn only while you are pumping, this bustier fits over your nursing bra. You lower the flaps of your nursing bra and insert the pumping attachments into the holes over the nipple. Once everything is in place, both of your hands are free for whatever you want to do with them. The Easy Expression Bustier is an example of this system. Medela also makes a hands-free kit that fastens any of their bras to their pumps’ parts.

Pain While Pumping

Pumping your breasts should not be painful. If it is, it is important that you discontinue whatever practice is causing the pain, as this may be an indication that you are damaging your nipple or breast tissue. Even if this isn’t the case, the pain will interfere with your ability to let down your milk.

One possible cause for discomfort is if you have a small pump that takes too long to generate a high enough suction before it releases the pressure (this causes discomfort for many women). Ideally, your pump should reach pressure after only a couple of seconds, then that pressure should be released. The suction levels should be high enough to get the milk flowing but no higher than that, as pressure that is too high for too long can damage your nipples. If you are having pain, try lowering the suction (which is sometimes labeled vacuum) until it is no longer painful. Please make sure that you don’t confuse the suction setting with the speed setting if your pump has both features.

If pain persists after you have adjusted the suction, it may be that you don’t have a good fit with the breast flange. Sometimes moistening the flange of your pump before you apply it to your breast may end your discomfort. Your breast should be centered within the flange, and your nipple should not be too large for it. If you have trouble seeing whether your nipple is centered within the flange, ask someone to help you. If that flange is too small, there may be friction right on your nipples, which will make them sore very quickly. Again, only Medela and Ameda make pump flanges with larger nipple tunnels for those women who need them. Keep in mind that your nipple may look wider to you when it is drawn into the tunnel.

Storing Milk

Your milk will keep for eight to ten hours at room temperature in a clean, covered container. You can store it in the coldest part of your refrigerator, where it will last three to five days, or in your freezer, where it will last up to six months. Your refrigerator door is the warmest part. Don’t be surprised if your refrigerated milk separates. Try to gently swirl it to recombine it before use. Don’t vigorously shake it, as this has been shown to damage the milk. Reheat frozen milk in a bowl of warm water. Never microwave it, as this destroys essential nutrients. After you thaw frozen milk, you should use it within twenty-four hours. You should not refreeze your milk.

It is best to freeze your milk in either glass bottles (being careful not to fill them too full, because frozen milk expands) or plastic bottles made especially for freezing milk. Ordinary resealable kitchen plastic bags are less durable, so it’s hard to seal them once they are filled, and the seams sometimes burst when the bag is frozen. Besides, there are other problems with storing food intended for your baby in soft plastic bags, which I’ll explain below.

Most working moms will need two sets of storage bottles: one to pump into that day and another, containing the previous day’s milk, to take to child care.

The average woman makes between three and five ounces of milk per feeding, or thirty-two ounces or so per day. This amount doesn’t increase over time—women don’t need to produce gallons of milk, as cows do—because the number of calories per ounce in your breast milk will increase automatically to meet your growing baby’s needs. And since breastfed babies are very efficient, their resting heart rates are lower than those of formula-fed babies, so they need fewer calories. This is one explanation for why breastfed babies have lower rates of adult obesity.

Soapy-, Metallic-, or Rancid-Tasting Milk
That You Have Thawed

Many women find that their babies refuse to drink the thawed breast milk they pumped and froze days or weeks earlier. When the moms taste the milk themselves, they understand the reason: It has developed an unappetizing taste that mothers variously describe as soapy, metallic, rancid, or gross. The problem arises because the milk has an abundance of lipase, the enzyme that breaks down fat in the milk. If this is your first try at freezing and storing your milk and you are thinking of stockpiling as much as possible, it’s a good idea to test-thaw some of your first batches of frozen milk to see if it has kept its good taste. It’s no fun to throw away the milk you worked so hard to express. Test it weekly for a while, as lipase may continue to break down fats even in the freezer; this way you’ll learn the “freezer longevity” of your milk (this varies from woman to woman).

There is a way to reduce the lipase in the milk that you intend to freeze, which can prevent your frozen milk from developing a nasty taste. Scald it just after pumping (the scalding point is when bubbles form around the edges of the pan before the milk reaches the boiling point). Next, cool it as quickly as possible and place it in bags or bottles in your freezer. Boiling the milk destroys some of its immune factors and nutrients, so be sure to take the milk off the heat before it boils.

It’s better not to use a microwave for scalding your milk if you can figure out an alternative. Some women use a bottle warmer to scald their milk, whether at home or at work. They usually say that their milk tastes better when processed this way than when it’s scalded on a stovetop. If you choose the bottle-warmer method, you should heat the milk to at least 145 degrees for one minute or 160 degrees for fifteen seconds (use a digital cooking thermometer to test). Next, put the bottles of scalded milk into a large container with ice water in it and, if possible, into the fridge at work. Once you are home, you can transfer the milk into the bags or bottles you’ll use for freezer storage. A deep freezer works better for long-term storage than the freezer compartment in your refrigerator. Remember: If you decide to use glass bottles or canning jars placed in a pan of water for the heating process (in order to avoid heating plastic), be careful not to put the hot glass containers of your scalded milk into cold water right away. Doing so is likely to crack the glass. Let it sit at room temperature until it cools enough for you to be able to pick it up. Now it can be transferred into the containers that you’ll put in your freezer.

Some women find that quicker thawing of the frozen milk makes for a better taste than thawing the milk in the fridge over a period of hours before use. If your thawed milk tastes bad to you but your baby doesn’t reject it, don’t worry. The high-lipase milk is not harmful to your baby.

A couple of other factors seem to affect some women’s milk-storage problems. Omega-3 supplements, flaxseeds, and DHA supplements have all been reported to intensify the taste deterioration of frozen milk.

Buying Toxin-Free Products

We all know how convenient plastic can be when it comes to food storage. It’s inexpensive, light, flexible, transparent, and durable. What many of us fail to realize is how unstable many plastic products are and how using them can introduce many unwanted chemicals, which may have adverse effects on health and normal development, into our bodies and those of our babies. This is a particularly important consideration for working mothers who will be bottling their milk.

One category of such chemicals, phthalates (pronounced “THAY-lates”), has been widely used in many of the products with which we come into contact on a daily basis. Phthalates are carcinogens that, when combined with polyvinyl chloride products (PVCs), form a flexible and durable kind of plastic that has been used to form countless consumer products. Phthalates can be found in plastic bibs, plastic wrap, plastic shower curtains, vinyl flooring, and countless plastic toys. They are also much used in medical equipment, including tubing and intravenous lines and bags. Until recently, they were present in most plastic pacifiers, nipples for baby bottles, and teething rings, and some of these products may still be available for purchase. (Please note: Don’t buy used plastic pacifiers, nipples, or teething rings.) Phthalates are also found in some nonplastic products, such as shampoos, skin lotions, and detergents. A study published in 2005 by the Centers for Disease Control (CDC) found that seventy-five percent of the participants tested had detectable levels of phthalates in their bodies.6 Those tested were all over the age of six, but all indications are that the levels of phthalates would have been even higher in babies.

The European Union started the debate on the toxicity of phthalates by passing a ban on the use of these chemicals in pacifiers, nipples, and teething rings in 1999. This came after advocacy groups such as Greenpeace began to publicize the results of animal studies revealing the adverse effects upon the male reproductive system. Such a ban has still not been passed in the United States, although some manufacturers now offer “PVC-free” pacifiers, teething rings, and toys on a voluntary basis.

Other health problems that have been linked to phthalate contamination include genital abnormalities in young males, premature breast development in girls, and poor brain and nervous-system development in both genders.

Many of us have become addicted to the toxic hard plastic products containing bisphenol A (BPA) used in baby bottles, other food containers, and the linings of food and beverage cans (including those containing infant formulas). BPA mimics estrogen in the body and seems to interfere with the bodily processes in which estrogen plays a key role. These include ovulation and reproduction.

When the advocacy organization Environment California tested five leading brands of baby bottles, it found that all five bottles leached BPA when they were subjected to the temperatures reached in most dishwashers. The levels of leached BPA were equal to those that caused harm in laboratory animals. Adverse effects included impaired sperm development, early onset of puberty in girls, higher rates of Down syndrome, impaired immune response, and higher rates of miscarriage. A 2003 study showed that even very low levels of BPA were associated with chromosomal abnormalities in laboratory animals. Don’t believe the labels on plastic products stating that they are “microwave safe.” An analysis carried out by the Milwaukee Journal Sentinel found that ten out of ten “microwave safe” plastic containers leached BPA.7 Canada has declared BPA a toxin and has taken steps toward banning it from baby bottles, infant formula, and other children’s products. The Food and Drug Administration, on the other hand, has declared it to be safe.

What to Use and What to Throw Away

Most plastic products have recycling codes printed on them. Often, there is a number inside the recycling logo.

Whether for babies or older members of the family, you can use codes 1, 2, 4, and 5 for storage (but never in a microwave or oven), and you should throw away any products with codes 3, 6, and 7. However, if you wish to lower your family’s exposure to potentially toxic plastics, it would be wise to store all food in glass or ceramic containers.

Also, follow these simple points:

·   Avoid sippy cups made of polycarbonate, because these can leach chemicals. Brands made from polypropylene or polyethylene are safer.

·   Avoid Styrofoam. Insulated mugs with stainless-steel interiors are better.

·   Avoid plastic wrap (it’s polyvinyl chloride). Use waxed paper instead.

Don’t forget that vinyl flooring often contains phthalates and that your crawling baby or toddler is likely to spend a lot of time on the floor. Look for flooring that doesn’t contain chemicals that outgas (cork or hardwood flooring are good choices).8

Finding the right balance between a necessary, safe, and ecological use of technology while staying close to nature in all possible ways is one of the greatest challenges of being a mother in the twenty-first century. Every woman who manages to continue breastfeeding even though she has an outside job makes that path a little easier for those who come after her.