Overcoming Early Breastfeeding Struggles

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Shannon Thompson, DO:

We often hear that breastfeeding is the most natural thing in the world, but for a lot of moms, it doesn't always feel that way. The truth is, it can bring a lot of unexpected hurdles and a ton of self-doubt. You find yourself asking, "Am I doing this right? Why does it hurt? Is my baby eating enough? "I'm Dr. Shannon Thompson, a pediatrician at Cleveland Clinic Children's, and today we're answering those questions.

Joining me today is my colleague, Dr. Adrienne Millner. She is a breastfeeding medicine specialist at Cleveland Clinic Children's. Welcome to Little Health, Dr. Millner. Please tell us a little bit about yourself.

Dr. Adrienne Millner, MD:

Thank you so much, Dr. Thompson. It's wonderful to be here. So my path to becoming a breastfeeding medicine specialist is somewhat non-traditional. I actually started out as a breastfeeding parent and many years ago. And it was through community support that I got started supporting breastfeeding parents, first as just a member of that community and then I went through an accreditation process to lead support groups. And then it was after that that I decided to become an international board certified lactation consultant, and I had a private practice, and then I went back to medical school. So it was really breastfeeding that brought me into medicine.

After that, I did residency in obstetrics and gynecology. And breastfeeding continued to be a very, you know, important interest to me throughout my training, throughout my work in obstetrics and gynecology. And so last year, I came here to Cleveland Clinic to focus exclusively on breastfeeding medicine.

Dr. Shannon Thompson, DO:

Thank you. We are so glad to have you, and so are our patients. Let's just start at the beginning. If you had to pick one thing that you want parents to know, especially expecting mothers about breastfeeding, what would that be?

Dr. Adrienne Millner, MD:

So I think that for me, the most important thing for people in our culture especially to hear is that they're not alone in breastfeeding and wanting to breastfeed in, you know, all the joy and all the, the struggles that may arise. And I think that, you know, one thing that my patients when I was practicing general obstetrics and gynecology would say was helpful to them to hear ahead of time was that, you know, their body was taking care of their baby during pregnancy and their body would continue to take care of their baby after the baby was born, and that that would help them sort of with the confidence piece in those first, you know, three to five postpartum days when things can get really challenging.

And I think that going along with that, what I would love for everyone to have a feel for is what normal looks like. And, you know, so they're not thinking there's a big problem when there isn't one, but also when they can recognize when there is a problem. SoI think all of those pieces are important, and I think that we need to do a better job -

Dr. Shannon Thompson, DO:

Yeah.

Dr. Adrienne Millner, MD:

In all those areas.

Dr. Shannon Thompson, DO:

Yeah. I love that, you know, that their body's continuing to take care of the baby and making it kind of a natural transition instead of what might be kind of confusing or, or trouble for them. Starting with some basics, you know, we see a lot sometimes on social media about breastfeeding. Can you tell us what, what is colostrum? What is it for? And when does it come?

Dr. Adrienne Millner, MD:

Yeah, it's a great question. Socolostrum in the, in the first few days, postpartum humans and mammals in general produce small amounts of milk called colostrum. And this is normal for humans, both the small amounts and what is in colostrum that's a little bit different than, you know, what is in breast milk later on. It'svery high in immune factors, and its main function is not actually nutrition, but protection. And so what it does is it helps to protect the babies against disease. And it's both short-term and long-term.

In some ways, this is the most valuable milk we produce as humans, even though it is in very small amounts. And that is normal. There's no need for larger volumes in those first few days, and that's one of the things that I think we don't know culturally. And it's therefore common for brand new babies to breastfeed very frequently because their stomachs are small and the colostrum is in those small amounts. They're kind of getting a little bit very, very often throughout the day.

Dr. Shannon Thompson, DO:

I think that's a really good point. You know, first of all, what, just how important it is, but also that the baby doesn't need a, a large volume of milk, a large, you know, either nurse or full bottle. A lot of people, you know, kind of feel that breastfeeding is very natural and it may come easy. That's not always the case, right? How do we kind of reframe that or, you know, kind of n- normalize the feeling that, you know, there might be some challenges, it might be frustrating, but as you said before, it shouldn't be isolating. And how do we support those moms?

Dr. Adrienne Millner, MD:

Yeah, absolutely. So unfortunately, in our culture, we rarely see breastfeeding. And so the images that we do see are often somewhat misleading and not very helpful. The things that we hear may not be very helpful. And we may have no one in our family who knows anything about breastfeeding or had any experience with breastfeeding. We may not know anyone else who has ever breastfed. This was definitely what my experience was like. And so it's hard to feel like it's up to us to do something so important and not know anything about how it's supposed to work. So while babies are born with, in most cases, unless they're very premature, feeding reflexes, which are, you know, sort of their way of starting that quote, natural process, humans have also evolved to live in communities where we support each other. And so it is very normal to need some help with this.

Dr. Shannon Thompson, DO:

Mm-hmm. I think we're used to being independent, you know? And I think a lot of that last part of pregnancy and what comes next is a mystery for moms. So the community and the support is, is just vital. You see your pediatrician a lot in the first, you know, couple of months, even the first year. But in that first week, you know, when things are really difficult or things are confusing, maybe not even difficult, how can a mom or how can the parent tell, is their baby getting enough milk? You know, are they satisfied? Are they sleeping and eating well? What are some of the signs they can look for to make sure that their baby's getting enough milk?

Dr. Adrienne Millner, MD:

Yeah. So I think we've talked a little bit about this, but I cannot overstate the importance of understanding what normal postpartum milk production is like. And I think this is an area where there is a lot of confusion, especially in healthcare settings, unfortunately. Often supplementation is recommended based on things like fussiness or actually a normal amount of weight loss. So it's important to know what that is. And it can often be really hard to tell, unfortunately, based on things like even wet diapers. The diapers that most of us are using these days, often they think they're wet. Are they actually wet enough? It can be really hard to tell. And babies are often breastfeeding more often than they would bottle feed. And so that can be, you know, distressing or confusing too. So it is really common to worry about milk production. Fortunately, there are some resources that can help.

Again, that, you know, support, I think, is an essential part of the postpartum period. And we're only starting even in obstetrics and gynecology, that fourth trimester idea is really, really new. And we really haven't, you know, increased support appropriately yet. And so there are so many resources out there. It's just, you know, how to access them, right? So there are lactation support groups, inpatient lactation consultants, breastfeeding medicine, of course. Lots of community support exists. And it can be, I think, hard for parents to anticipate, you know, needing these things. So it's kind of up to us to help them, you know, access those resources.

Dr. Shannon Thompson, DO:

I think that that's really good advice. And I think even as a pediatrician after I had my first baby, I, I would say it was, it was a hot mess at best, you know? Even knowing the things that I do know. And I didn't know what community to reach out to or, you know, where to seek support and often felt like I shouldn't need to. So I think normalizing, you know, that community, that village that we always talk about is, is really important for new moms and new families.

Dr. Adrienne Millner, MD:

Mm-hmm. And just the lack of, you know, pediatricians, I think, are put in the role of needing to know about breastfeeding. And as I'm sure you remember in medical school, there is very, very little education even today, which is, of course, part of our mission is to address that. But there's no, like, standardized curriculum about it, and there are almost no questions on our, our board exams about it. So we're supposed to know everything, and most physicians know what they experienced, and that's about it.

Dr. Shannon Thompson, DO:

And that makes it hard to counsel our parents. So thinking ahead, you know, for a new mom or an expecting mom who, who hopes to breastfeed, or is starting to breastfeed, what are some common issues that you see or challenges? You know, what can l - what can be normal to, to kind of work through, and what isn't?

Dr. Adrienne Millner, MD:

So, you know, the way that I think about this question is, again, just that lack of support in the culture is one of the biggest challenges for us to overcome, like, in the workplace and just in general. You know, that's pretty much obvious in the United States. We have a real deficit in parental leave policies and workplace accommodations. That challenge starts early, unfortunately.

But some of the common problems that I see in my practice are ineffective breastfeeding. That can be a hard one to spot. Initially, it's often just seen as what will result in low milk production, and rather than there was actually a cause for it, that pumps are widely used, but they are almost never fitted well or there, there seems to be... most patients I see don't know how to use the settings. And because of their wide use, I think that we really need to address that prenatally.

All of this can result in low milk production. It can result in slow infant growth. And so those are two of the main presenting complaints that I see. And then two of the most common reasons for that. Another thing that I see a lot of is breastfeeding associated pain, breast inflammation, and mastitis.

Dr. Shannon Thompson, DO:

Should a mom ever push through pain? You know, keep going, kind of white knuckle it, or should they figure out what needs to change, you know, seek help? It's your opinion or your, your thoughts on that.

Dr. Adrienne Millner, MD:

Yeah, I think that that's a phrase that I've heard many times. It's something that I heard myself on, I think, postpartum day three. And so I, it, I would say it's never recommended to push through pain. If something is painful, it should be investigated. Sometimes there can be some tenderness just because, you know, breastfeeding is a new thing, but pain should always be investigated. It's something that can indicate, you know, that there is a need for more support at a minimum. And so that's, that's something that I think is often not investigated soon enough.

Dr. Shannon Thompson, DO:

I think as moms, sometimes we, we sort of are, are built that way, right, to kind of put ourselves last and push through for our, our children. So I've heard many times, like, "Oh, it's painful, but I can, I can do it." Or, like, you know, it's a little bit, you know, sore, not a big deal, but that is a big deal. And I, and I think that Dr. Millner definitely is right that if you're feeling that, then, then you should look for some help, and, and we are always here for you.

Hot topic is ties. Lots of talk about ties on, you know, TikTok, social media, tongue ties, lip ties, even cheek ties. Um -

Dr. Adrienne Millner, MD:

Yeah.

Dr. Shannon Thompson, DO:

What does that look like? What is a tie that might impact feeding? And what is a tie that should be left alone or just is the normal part of a baby's mouth?

Dr. Adrienne Millner, MD:

This is a great question. It definitely goes back to the topic of pain and something that we are asked to evaluate fairly frequently and we do evaluate. So unfortunately, just as you were alluding to, there is a lot of misinformation out there on this topic. And of course, many other topics related to breastfeeding.

So one thing that we don't recommend is, you know, there is not the evidence for doing procedures to remove or to cut things like the membrane under the top lip or anything in the cheeks related to feeding. There is no evidence that this does anything but cause pain. It can cause feeding aversion. And also has not been shown to improve breastfeeding or other related outcomes. Occasionally, the finulum under the tongue is restrictive. And so that's something that we evaluate fairly commonly. And I would say for my own patients, and I believe my partners are similar in this, we often do not recommend what's called a phrenotomy or just sort of, you know, an incision in that connective tissue.

The reason is not all breastfeeding problems are caused by tongue ties. And tongue ties don't always cause breastfeeding problems. So you have to look at, is there, you know, persistent breastfeeding associated pain and trauma that is not addressed in other ways? Is the baby able to breastfeed effectively? And if the answer to those two things, you know, are negative, then almost always, there's nothing that needs to be done. And then they're kind of different. There's a scoring system that we use to help sort of determine the likelihood that something would need to be done. It is a very simple and safe procedure if it does need to be done. But I've certainly seen many cases where phrenotomy was performed and breastfeeding was still not effective. That was not actually what the problem was.

Dr. Shannon Thompson, DO:

Yeah. I think that's, um, you know, natural thing to kind of look to or go to hoping that, you know, something will be easily cleared up. The other misconception that I hear, you know, about tongue ties or even lip ties in the office, not infrequently, is that they can cause speech delays or speech abnormalities down the road. And there's not any medical evidence that shows that. You know, at this point, we continue to look into those things and we continue to always pay attention to our patient's development. But at this time, tongue tie, lip tie, it doesn't impact our speech down the road. So that's another thing that hopefully can ease some minds about this.

Dr. Adrienne Millner, MD:

Mm-hmm. Yeah.

Dr. Shannon Thompson, DO:

Another thing, you know, which we hear a lot about or that breastfeeding moms deal with is when they get engorged, they get full of milk, they get what we call plugged ducts. And of course, down the line from that, you know, inflammation or even mastitis, which is an infection of that breast. How can a mom safely manage this either on her own or when does she need to seek help?

Dr. Adrienne Millner, MD:

Well, I would say that we are always available. So if there's any question, I am always happy to help patients with issues like these. And you're absolutely right. There's so much misinformation, outdated information, and honestly, even some harmful marketing that's related to this topic of products that can really make things worse and cause some pretty serious complications. So generally speaking, if there's a product you need to buy, I think you should not. That is not necessary and may be harmful.

So fortunately, Cleveland Clinic has great patient information available, searchable online on this topic. So, you know, I can go over a little bit of the basics, like things that we don't recommend anymore, but it is out there. And so it is findable and it is up-to-date. Used to be recommended to do lots of heat and massage. That can actually be quite harmful. And so now we sort of, you know, with any breast inflammation, which is really kind of what this topic is about, you know, we, we recommend kind of cooling things off, ice packs, getting the lymphatic system to get rid of that extra fluid.

Most of it, it feels like there's a ton of milk in there, but a lot of it is just inflammation related to all that, you know, metabolic activity and blood flow.

Dr. Shannon Thompson, DO:

Very good. I do think that there's a lot of that information floating around out there, and I hear it often in practice. Another topic, you know, that moms worry about is, is what they're eating affecting how the baby's feeling? And more specifically, their gas. You know, babies are gassy. Is this coming from breastfeeding, something that mom's eating?

Dr. Adrienne Millner, MD:

That is such a great question, and I address it almost every visit. And so there's this sort of, you know, common misconception out there that if you're eating something that gives you gas, it will give your baby gas. And actually, that is impossible. And so the thing that causes gas in adults when we're eating, you know, beans and broccoli and stuff like that, those compounds are generally sugars and other things that stay in our gut and feed the bacteria there and the bacteria make the gas. And because they're staying in our gut, they don't ever get into the blood. And if something doesn't get into the blood in our blood, then it cannot get into breast milk. So it's impossible. Babies have gas. It's just a fact of being a baby. Human milk is very high in lactose, which is actually the way it's supposed to be.

This is what we need to grow those little baby brains into, you know, big kid brains. And so that may cause some gas, but really it's just kind of, you know, astonishing to me how loud gas can be in such a tiny little person.

Dr. Shannon Thompson, DO:

<laugh> That's true.

Dr. Adrienne Millner, MD:

Um, and it can seem very distressing and they sometimes don't know what to make of this, but it is not actually harmful and you don't need to change your diet.

Dr. Shannon Thompson, DO:

Yeah. Yeah. I often say in clinic is, you know, being a baby is hard. They, they have to do everything for themselves for the first time. And digestion is one of those things. So frequent, loud, even uncomfortable gas is common. And we can help you with some conservative kind of measures for that, but rest assured that it's nothing that you're eating or that mom's eating that's causing that because, you know, the big thing is we need you to be healthy too.

On the topic of health, medications while breastfeeding while lactating is another hot topic. You know, there's, there's a lot of information out there that's not true or maybe is true, you know? Uh, how do you counsel moms on what is safe, what's not safe, and where to look for that information?

Dr. Adrienne Millner, MD:

Yeah. So this is another thing that I am happy to see anyone for, any time to discuss these things. And the good news is that there are very few medications that are contraindicated or unsafe for breastfeeding. Unfortunately, this seems to be the opposite of what people hear. And there are, you know, some great resources out there for caregivers, but there's unfortunately, like we were talking about, little to no standardized medical education on how to prescribe for this population. That's something that we're working to change.

But it's suddenly you're expected to be an expert and the, you know, the physiology of two people that are, you know, their health is intertwined and you never got a lecture on that. So it can be, it can be challenging. If I do recommend prenatal consultation, if you're someone who is on a medication or may need to resume a medication and you wanna know if you can breastfeed and your doctor's not sure, I think that that would be a totally appropriate thing to discuss ahead of time to be prepared.

Fortunately, as breastfeeding medicine is growing as a specialty, we are, you know, providing this for patients and other caregivers to help kind of fill that gap so that they can understand, you know, if there are any risks and what the alternatives are. But again, it's rarely necessary to even change a therapy. It's just, you know, most medications, especially over-the-counter ones, are generally safe.

Dr. Shannon Thompson, DO:

That's very reassuring to hear. Dr. Millner, you mentioned doing, you know, prenatal consultations or, or postnatal consultations. Could you enlighten us what an appointment with a breastfeeding medicine doctor might look like? You know, what's the difference between that and a lactation consultant or even a lactation counselor? A few thoughts on that?

Dr. Adrienne Millner, MD:

Yeah, there are, there are so many sort of pathways to doing breastfeeding support now. So the range of options for support, you know, like I said, there's community support, there's accredited community support, which I think is important just if you're going to a support group that people have training. The CLC or certified lactation counselor, that's a course that people can take if they want to support breastfeeding parents. The IBCLC or International Board Certified Lactation Consultant is... that is a process that took me several years. It requires clinical hours. It requires an exam and required education. It's very standardized and it needs to be updated every five years. And then for us, for breastfeeding medicine specialists, because I kind of have both of these things, we're physicians or we do have some advanced practice, like, uh, nurse practitioners as well.

But for, you know, for a breastfeeding medicine specialist physician, you know, we have medical school residency in some related field. Sometimes family medicine, pediatrics, OBGYN are fairly common, but there are breast surgeons as well who have done this. And then we have to go and find that additional training after all of that is done. And then you had more of that question more about, like, what our appointments are like or -

Dr. Shannon Thompson, DO:

Yeah. If, if, for, you know, if a patient or a mom is scheduling to come in to see you or one of your colleagues, you know, what, what might they expect from that visit?

Dr. Adrienne Millner, MD:

Yeah. So again, it kind of depends on what the complaint is or what the issue is. Like, if it's a mastitis complaint, there's sometimes just, you know, focus on that alone. But, you know, this is. All of these things are kind of interrelated. It's like, why did this happen? So in most appointments, it's for the mom and the baby, you know, breastfeeding parent and baby, or babies sometimes. And it includes, you know, for me, it's, you know, a thorough history and physical exam for both on all related organ systems. And then a breastfeeding assessment in terms of, you know, if baby is going to the breast, which many of them are, or if there is pumping a pump assessment, or both in many cases. And that would include things like, you know, a measurement. And it's, again, you know, a moment in time, but, like, how much, you know, breast milk is a baby able to get from the breast during a, you know, hopefully typical feeding or typical pumping session.

And so, you know, all of those things and more are addressed during that time. And then these are, you know, fairly long visits because there's, you can't really rush a baby who's breastfeeding. But also, there's just a lot to take into account.

Dr. Shannon Thompson, DO:

I think that sounds like a really good way to, to get to know, you know, your, the patient and, you know, the breastfeeding and get some, some good help. Kind of, you know, on the, on the lines of support, returning to work. A lot of moms are headed back to work, you know, maybe quicker than we would like or quicker than any of us would, would think is, is helpful. How do we support these moms? How does the family or the workplace support them as they're going back to work and maybe transitioning into a different feeding, whether it's pumping, you know, or, or taking more breaks?

Dr. Adrienne Millner, MD:

Yeah. So, I mean, I think family support starts, of course, at the beginning. And I think it can be hard sometimes for family members to think of how to support the breastfeeding parent. They sort of think, like, "Well, if I can't feed the baby, I can't really help." And obviously, that is not true. If you think about it for just a moment, there's so many things that need to be done. You know, I always advocate for, you know, for baby showers instead of, you know, a bunch of stuff. Like, meals are super helpful, cleaning the house, things like that, that you just do not have time for when all you're doing is caring for a new baby. So I feel like that support, you know, can start really early on and should.

And then, you know, it's, you know, for the workplace, uh, yeah, you're absolutely right. It, a lot of this return to work is so soon, and it's just so hard to, you know, to be separated that, that early in the process. And it's not like that in most other countries, but it is here. So there are some resources out there for workplaces. And, you know, I think Cleveland Clinic has a fantastic policy to support breastfeeding parents. But there's also the business case for breastfeeding at womenshealth.gov. It kind of has, you know, some examples of work accommodations and also the benefits for families and employers. They may not even understand that this benefits them too. And they should do it anyway, but it's nice that it, that it does. So I would recommend at least, you know, checking that out. And I do write a lot of letters for my patients to help their employers understand what their needs are gonna be.

Dr. Shannon Thompson, DO:

Yeah. I think definitely we, you know, moms worry about that, whether it's just separation from baby or, you know, how are they gonna keep up. But one of the big questions and something that we see a lot on, again, on our social media is the freezer stash. You know, do we need a big, deep freezer of frozen milk for work, for a baby? How do we make sure we have enough milk for our baby and also enough to keep for when we're not in the house?

Dr. Adrienne Millner, MD:

Yeah, this is a, a very common, you know, thing that, that I'll do consults just for this, because it's just such a common question. And it can be scary and confusing. And they're, you're absolutely right. The, the social media seems to be inundated with accounts of, you know, people who claim to be producing huge amounts of breast milk. Obviously, these are, you know, what they claim. It's very unlikely to actually be true in many cases. And, you know, what I find for patients that have, that store up a lot of milk is most of them do not know what to do with it in the end because they don't end up needing it. And so for people who you, if you know when you're going back to work, you know how long you're gonna be gone, you know, what the caregiver situation is going to be, then it, you know, you can start to plan out gradually storing small amounts so that you end up having about one day's worth of breast milk plus maybe a little extra.

And that's kind of what you need because when you're separated, the idea is that then you will, you know, pump on a similar schedule or at least at appropriate intervals to be able to leave what ends up being about an ounce to an ounce and a quarter per hour. It's not as much as we see these big bottles of formula in, you know, the media. It is, it is nothing like that with breast milk. And I think that's when one of those expectations that people end up with kind of the wrong idea and they get really worried they're gonna have to produce a big jug of milk. And so, you know, I think it's important, especially in the early days when you're building up your milk production and babies learning how to breastfeed, not to start storing a lot of milk really early. Babies need to get that milk.

And so one cause that I see of slow weight gain in the beginning is a lot of milks going in the freezer, not in the baby. And so it's, you know, sort of the general recommendation, if it's possible, is for breastfeeding to sort of be quote, established. So that's around the first month or so. And then kind of develop a plan for saving up a small amount each day or every few days until you get the amount that you need. And then the milk storage, there's some great searchable information on the Cleveland Clinic website.

Dr. Shannon Thompson, DO:

Obviously, this is a big topic and there is a lot to cover. Cleveland Clinic is here to support you in those goals. We have individual appointments, support groups, shared appointments, virtual appointments. So Dr. Millner, if we're looking for you or if one of our moms is looking for you, where, where can we find you?

Dr. Adrienne Millner, MD:

So there is information on the website, uh, the breastfeeding medicine division, and I personally am in the Akron office, and then we do have other partners in various parts of the Cleveland area.

Dr. Shannon Thompson, DO:

Great, thank you. It was wonderful to have you. Breastfeeding can look different for everybody. Whether it's your first time or your fifth time, it may be something that you need some help with. It's a learned skill for both you and your baby. Give yourself grace while you figure it out. If you need additional support or you wanna schedule an appointment with the breastfeeding medicine specialist at Cleveland Clinic Children's, including Dr. Millner, please call 216.444.KIDS. That's 216.444.5437.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts, or visit clevelandclinicchildren's.org/littlehealth.