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	ask the experts cynthia good mojab

Cynthia Good Mojab, MS, IBCLC, RLC
Breastfeeding

• Improper Latch
• Traumatic birth
• Nursing and ovulation
• Lactose overload and lactose intolerance
• Insufficient supply of breastmilk
• Tandem nursing limits
• Pregnancy and weaning
• Antiobiotic and thrush
• Relactation
• Baby reacting to mother's foods
• Breastfeeding and miscarriage
• Post partum depression, estrogen cream, and milk production?
• Relactating after formula use
• Chemotherapy and breastfeeding
• Flu shot and antibodies through breastmilk
• Mammogram and breastmilk
• No breastmilk production
• Distance coparenting and breastfeeding support
• Menopause and milk supply

After enjoying delightfully successful breastfeeding relationships with my first two children, I am having an issue with my third. He is 13-months old-and has four teeth on top. While he never noticeably bites me during breastfeeding, I have to assume that his teeth are pressing or gouging into my flesh. I have developed wounds on both sides in the spots where his two top teeth touch me when we nurse in our usual cradle position, and sore, red spots from nursing in other positions. His teeth are hitting a millimeter out from where my nipple meets the areola. I thought babies were supposed to be getting more areola in their mouths than that. What should I do? Has my son suddenly developed an improper latch, and is he too old to retrain (he sure can get bossy!)? For now, breastfeeding is excruciating, and I don't know what to do. My doctor, of course, can't imagine why I'm breastfeeding my 13-month-old anyway, and recommends that I stop. I DEFINITELY don't plan on stopping, but what can I do about these wounds and the terrible pain?

I'm sorry you are in so much pain! And, I'm sorry your doctor has been less than helpful. A 13-month-old is not at all too old to be breastfed. In fact, the American Academy of Pediatrics recommends at least one year of breastfeeding and the World Health Organization recommends at least two years. A nursling's latch remains important throughout the duration of breastfeeding. And, yes, sometimes latch problems can develop well into the breastfeeding relationship. When teeth put pressure too close to the nipple, it can result in exactly the symptoms you are describing. A deeper latch should help your wounds heal and prevent new wounds from forming. There are several aspects of a good latch that you might be able to improve. First, nurslings tend to get attached better to the breast when they attach themselves. Second, being skin-to-skin with your baby can help trigger breastfeeding reflexes that facilitate comfortable breastfeeding. That said, as babies get older, they can turn into little gymnasts at the breast and even an initially good latch can deteriorate during a feeding—especially when a nursling falls asleep. So, you still may need to watch for how your baby is latching on and encourage behaviors that contribute to more comfortable breastfeeding. For example, what part of your son's face is aimed at your nipple just before latching? It should be his nose, which will mean that he needs to tip his head back a little and open wide in order to latch on. You can also model a wide latch by saying ?wide? and opening your own mouth wide as he latches on. What part of your son's face meets the breast first as your son is about to latch on? It should be his chin. Does your nipple show signs of compression just after nursing? If it has a somewhat angled appearance—like a new tube of lipstick—or if there is a white or red compression stripe across the tip of your nipple, then the latch was too shallow during that feeding and your nipple was compressed between your son's hard palate and tongue. Better support of the arm that holds your nursling's weight during breastfeeding can help keep your son more deeply on your breast. You can experiment with one or more pillows under your arm or a rolled up towel behind your son's back if you are nursing in a side-lying position. Encourage your son to nurse in a position that avoids turning his head in relation to his chest. Varying your breastfeeding position—as you've been doing—is an excellent idea while you try to figure out how to help your son latch on more deeply. Pay special attention to when his latch seems better and when you are in less pain—what is different? In what position were you breastfeeding? How did he attach to your breast? Was he awake or asleep? Try to do more of whatever seems to be working better! Also, broken skin is at risk for bacterial infection as well as yeast overgrowth (thrush). If you don't have thrush, a little expressed milk can help your wounds heal. You can consider consulting a local International Board Certified Lactation Consultant. She can observe a breastfeeding session, offer suggestions, and direct you toward a physician who is more knowledgeable about and in support of breastfeeding—and who can help you assess whether you may have acquired a bacterial and/or fungal infection that needs treatment. The mothers of nursing toddlers in your local breastfeeding support group may have additional ideas for how to regain a comfortable breastfeeding relationship with your son. Best wishes!

Resources
Mothering Your Nursing Toddler by Norma Jane Bumgarner

The Latch and Other Keys to Breastfeeding Success by Jack Newman, MD

Baby-Led Breastfeeding: The Mother-Baby Dance by Christina Smillie, MD (DVD)

I experienced a traumatic birth with my now four-year-old son. Even after having a wonderful homebirth with my second child a year ago, I am still suffering guilt, grief, and overwhelming sadness related to my first birth. My son is a wonderful, spirited child, with many positive qualities; but he also [experiences] explosive anger and frustration and has never enjoyed being held. I have worked so hard to try and bond with him, but it still feels as though something is missing. I know that part of his [behavior] is just him, but I wonder how much is due to his birth experience. Do you have any advice as to how we can both heal from such a traumatic experience and better bond together? I am frustrated to the point of tears almost daily.

I'm so sorry to learn of your traumatic birth experience. I know that the terrible impact of trauma can ripple through a woman's life in ways she never expected. The challenges that you describe may very well be related, at least in part, to your traumatic birth. Let's take a look at trauma's impact on attachment first.

Attachment between caretaker and child is formed over an extended period of time. Influenced by both nature and nurture, it is the result of countless interactions between caretaker and child. The child experiences and expresses a need, which is met by the caretaker, and gradually he or she associates the resulting positive feelings with the caretaker. The caretaker, in turn, is satisfied that the baby or child is calmed and comforted. Baby/child wearing, cosleeping, massaging, breastfeeding and, later, hand-feeding contribute to meeting a little one's needs and thus help to build attachment over time.

Though attachment can be derailed by trauma and other life events, it can also be recovered. Responsiveness is a key component of the attachment process: a mother must recognize the baby's need and the baby must be able to receive her caretaking. If a biological or adoptive mother is unable to respond to her baby/child—because of grief, depression, trauma, separation, and so on—attachment can be undermined. It can also be undermined if a baby or child is unable to express his or her needs and then respond to the caretaking of his or her mother, whether because of a congenital or acquired disorder or illness, trauma, or pain.

Life experiences such as traumatic birth can result in a child who experiences explosive anger and intense frustration and does not enjoy being held. These qualities may also be part of how a child is "wired." Children's emotional expressions, including their ability to tolerate frustration and their desire to be cuddled, are varied. It's wonderful that you recognize that your son is a "spirited" child! This shows that you are tuning into the positive, as well as the challenging, sides of his behavior.

So, where to go from here? A holistic approach will take into account multiple aspects of your situation. First, your feelings of grief, guilt, and daily frustration suggest that you may benefit from counseling. Women who have been traumatized in birth need a safe place to work through their experiences. It is very hard to do this when so much of our time and energy is spent on mothering young children. Yet trauma and grief don't just go away. Ongoing or reoccurring symptoms are a call from within us to work toward healing, no matter how much time has passed since a trauma or loss. The challenge is to find a mental health-care provider who specializes in traumatic birth experiences. Carefully interviewing a potential mental health-care provider over the phone can help you determine whether he or she understands the significance of birth trauma. A counselor who thinks you should just "move on" and "focus on the positive" is not going to be helpful. As a matter of fact, such lack of validation can result in secondary trauma. But a skilled and knowledgeable counselor can be a meaningful part of the healing process. She or he can provide a psychological evaluation, help you look at possible physical causes of your symptoms, e.g., hypothyroidism, copper/zinc imbalance, caffeine or alcohol intake, lack of exercise, etc., and provide diverse treatment approaches. Moving forward in your own healing will free energy that you no doubt need for mothering—and for the rest of life.

Second, seek out support from other mothers healing from traumatic birth experiences. Knowing you are not alone and that your responses to your trauma are logical and normal can be very healing. There may be an International Cesarean Awareness Network (ICAN) group that holds meetings in your area. Even if your birth was not surgical, the group may be able to offer support and resources (such as suggestions for a therapist). Go to www.ican-online.org to locate a group near you and see the resource pages of my website (www.lifecirclecc.com) for additional help.

Third, your son's behavior suggests that he could benefit from an evaluation, too. That he does not enjoy being held could be a symptom of weak attachment, or it could be a normal variation of cuddling behavior. It could also be a symptom of a disorder with a biological basis, for example, sensory integration dysfunction. (See The Out-of-Sync Child, by Carol Stock Kranowitz, for a very readable overview of this disorder.) Whatever the cause for his behavior, working with a counselor who specializes in child development and mental health, as well as attachment and family systems, could help both you and your son enjoy relating to each other more. (Challenges in a family never fully reside in any one member; see the page on my website about family systems if you're interested in learning more: www.lifecirclecc.com/familysystems.html).

Fourth, learn even more about attachment. The wording of your question suggests that you have already read about attachment parenting in books such as Katie Allison Granju's Attachment Parenting: Instinctive Care for Your Baby and Young Child or on websites such as www.attachmentparenting.org, the site for Attachment Parenting International. Still, you might not know about other resources, such as the New Zealand-based organization, The Centre for Attachment (www.centreforattachment.com). Adoption literature also has useful information on improving maternal-child attachment in difficult circumstances. Even though you aren't an adoptive mother, you might consider taking a look at Attaching in Adoption: Practical Tools for Today's Parents, by Deborah Gray. This book outlines common challenges in attaching, offers down-to-earth ideas for therapeutic parenting, and describes situations in which professional guidance is helpful. Adoptive families who successfully attach can bring hope to birth families who are struggling to bond.

Fifth, many parents don't realize what a strong role diet can play in a child's behavior. Food allergies and sensitivities can impact emotions as well as overall functioning. Many children do not do well on sugar, artificial colors and flavors and other additives. Is This Your Child?, by Doris Rapp, MD, might help you identify whether food issues are contributing to some of your son's behaviors.

I hope my response is useful. A mental healthcare provider will help generate still more ideas and explore what approaches may work best for you. There are likely many factors contributing to what you are facing. Such complexity can feel overwhelming at times, but it also offers multiple opportunities for positive intervention. I wish you well on your journey.

I have a 2 year old son who loves to nurse and whom I love to nurse as well. The only snag in this relationship is that I still have not begun to ovulate (though I am aware this can happen anytime) and I would like to be able to conceive sooner rather then later. Do you have any ideas or suggestions on how to encourage ovulation/menstruation without just weaning my son?

How wonderful that you and your son are enjoying breastfeeding. As you may know, nursing at your son's age - and well beyond it - is both biologically normal and healthy. Anthropologist Dr. Katherine Dettwyler estimates that, if culture didn't tell us to do otherwise, the natural age of weaning would average between 2.5 and 7 years of age (Dettwyler 1995). Furthermore, many mothers do conceive while nursing another child. In spite of these facts, the "one size fits all" approach of completely stopping breastfeeding is one of the first things recommended by many people when a nursing mother's fertility does not return as soon as she wishes. Women's fertility responses to breastfeeding are actually quite varied. Gotsch (1991) reports the case of a woman whose periods had returned but who was unable to conceive until she weaned. But, I also know women who unexpectedly conceived a third child while tandem nursing an infant and a toddler - and they were not even menstruating! Because every woman responds differently to the hormonal changes caused by various breastfeeding patterns, there is no definitive way of knowing what conditions are required for a particular woman to conceive while breastfeeding. However, that's not a very helpful answer to your question! So let's look at a few things that are known about the pattern of breastfeeding that leads to delayed return of fertility: lactational amenorrhea. Then we can work backward from there for possible ways to increase fertility while continuing to breastfeed.

The Lactational Amenorrhea Method (LAM) provides more than 98% protection from pregnancy during the first six months after birth as long as a mother:

• has not experienced the return of menstruation AND
• does not supplement regularly or allow for long periods without breastfeeding during the day (more than four hours) or at night (more than six hours) AND
• is breastfeeding a baby less than six months old (Mohrbacher & Stock 2003)

We also know that a high partial breastfeeding pattern (supplements making up no more than 5 to 15 percent of a nursling's feedings), especially if breastfeeding precedes supplementation, can suppress fertility (Mohrbacher & Stock 2003; Gray 1990). When the vast majority of feedings are not at the breast, or the child is minimally breastfed on an occasional or irregular basis, then breastfeeding has been shown to have little impact on fertility (Mohrbacher & Stock 2003).

So, if a breastfeeding mother wants her fertility to return, but does not wish to fully wean her two-year-old child, she could consider engaging in one or more of these breastfeeding patterns:

• Decreasing the frequency of daytime breastfeeding (allow at least four hours between breastfeedings), while increasing table foods and drinks
• Decreasing the frequency of nighttime breastfeeding (allow at least six hours between breastfeedings), while increasing table foods and drinks
• Offering table foods and drinks before breastfeeding

Of course, your son's pattern of breastfeeding may already match the minimum breastfeeding intervals described above. In that case, you could experiment with gradually increasing the interval between day- and/or nighttime breastfeedings even more, while increasing table foods and drinks. There may be a certain number of times of breastfeeding during the day or night that you must be below in order for your fertility to return. On the other hand, there may be a certain number of times during the day and/or night that your son seems to need to nurse. It is clear from the wording of your question that you are already aware of the importance of attending to both your and your son's needs. You may find balancing those needs easy or difficult. If you do find it difficult, talking with a La Leche League Leader or International Board Certified Lactation Consultant may help you find the best balance given your particular situation.

Also, Humphrey (2003) Humphrey cites two older studies showing that "nursing mothers who used chasteberry for longer than two weeks had their periods return early." She describes how chasteberry (vitex) is used as the first treatment for infertility by many contemporary German physicians. She cautions that animal studies have shown that chasteberry may decrease milk supply (which will happen during pregnancy anyway); however, it has also been used traditionally to increase milk supply. And, she states this about chasteberry's safety: "May not be appropriate for self-use by some individuals or dyads, or may cause adverse effects if misused. Seek reliable safety and dose information." Humphrey also notes that some people experience allergic reactions to chasteberry. To make an informed decision about whether to consider this option, please thoroughly reviewand ask your health care provider to thoroughly reviewthe information provided on chasteberry in Humphrey's book, The Nursing Mother's Herbal. Since I am not a physician, I cannot suggest or recommend that you take or not take any medication, whether it is an over-the-counter, prescription, or herbal medication. Because of potential side effects (such as allergic and other adverse reactions) and interactions with other medications, no medication - including herbal medications - should ever be used without consulting a health care provider.

Because many factors can impact maternal fertility, such as nutrition, age, and hormonal levels, it is possible that something other than, or in addition to, breastfeeding is suppressing your return to fertility. A visit to your health care provider could be useful in ruling out or treating any other conditions that can decrease fertility. Other good resources for information about fertility, in general, and about increasing fertility while breastfeeding include:

• Breastfeeding and Natural Child Spacing by Sheila Kippley
• Enhancing Fertility Naturally by Nikki Wesson
• Fertility, Cycles, and Nutrition by Marilyn Shannon
• Taking Charge of Your Fertility by Toni Weschler
• Women's Bodies, Women's Wisdom by Christiane Northrup
• Your Fertility Signals by Merryl Winstein

And, finally, since there's nothing quite like the opportunity to consult other mothers who have had similar experiences, you might want to read the answers that mothers submitted to New Beginnings in response to a question very similar to yours. You can find their answers on the La Leche League International Website at: www.lalecheleague.org/NB/NBMayJune04p114.html.

References
Dettwyler, K. A time to wean: The hominid blueprint for the natural age of weaning in modern human populations. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter 1995, p. 39. Gotsch, G. Breastfeeding and Fertility. Schaumburg, Illinois: La Leche League International 1991. Publication No. 331-17. Gray, R. The risk of ovulation during lactation. Lancet 1990; 335:25-29. Humphrey, S. The Nursing Mother's Herbal. Minneapolis, MN: Fairview Press 2003, pp. 234-236, 272, 281. Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003, pp. 420-425.

What is “lactose overload” as opposed to “lactose intolerance”?

Lactose is the major carbohydrate in human milk. Its digestion requires the intestinal enzyme, lactase, which is made by the mucosal surface of the infant’s intestinal tract from birth. Lactose intolerance results from a decrease in lactase. Many mammals develop lactose intolerance after weaning. When this happens, it is called “primary lactase deficiency”: the biologically normal decrease in lactase that occurs with maturation. Among humans, adequate lactase is normally produced by the intestine until childhood. During infancy, primary lactase deficiency—and the resulting lactose intolerance—is rare. Lactose intolerance is most common in adults whose heritage is African or Asian.

“Secondary lactase deficiency” results in a temporary, reversible intolerance to lactose and can occur during infancy. Secondary lactase deficiency may result from feeding mismanagement, antibiotic use, or gastrointestinal illness. Lactose overload can result from feeding mismanagement, whereby the nursling consumes too much higher lactose/lower fat milk (the milk available earlier in a feeding and when the breast is more full) and too little lower lactose/higher fat milk (the milk available later in a feeding and when the breast is more empty). Symptoms include bright green, slimy, watery, and explosive stools that irritate the baby’s skin, increasing fussiness, and a great deal of gassiness. Nurslings whose feedings are timed (e.g., ten minutes on each side) or whose mothers have an oversupply of milk may never get the opportunity to nurse on an “emptier” breast. Thus, they may consume more lactose than normal, overwhelming their capacity to digest it. (Symptoms of oversupply include good weight gain in a baby who is gulping, choking and sputtering when her mother’s milk lets down.) The solution is to change how breastfeeding is managed so that the baby can consume normal amounts of fat and lactose in a normal volume of milk. Appropriate management techniques include, for example, letting the baby “finish the first breast first” (if feedings have been timed) and/or switching sides less frequently while expressing milk to stay comfortable (if the mother has an oversupply of milk). An International Board Certified Lactation Consultant or La Leche League Leader can help a mother sort out exactly what is happening in her situation and identify appropriate breastfeeding management strategies.

Bibliography
Mohrbacher, N. and Stock, J. "The Breastfeeding Answer Book". Schaumburg, IL: La Leche League International; pp. 116-117
Riordan, J. "Breastfeeding and Human Lactation". Boston, MA: Jones and Bartlett 2005; p. 579.

Should I be concerned about not having enough breastmilk to nourish my baby?

Many mothers are concerned about not having enough milk. Yet the likelihood that a woman will be physically unable to produce sufficient milk for her nursling is actually low. So why is this such a common concern? Part of the answer lies in our loss of the art of breastfeeding. Many mothers have grown up in families where they are the first women in generations to breastfeed. These mothers are pioneers, doing the best they can with the information and support available to them. Unfortunately, because they are breastfeeding in a formula-feeding culture, the information they receive may be inaccurate and the support they have may be inadequate-which can undermine their efforts to breastfeed. In addition, exposure to formula advertising and being given free formula in the hospital after birth can decrease the confidence of mothers in their ability to breastfeed.

Milk supply is dynamic. It follows the law of supply and demand. The more frequently and effectively a nursling breastfeeds, the more milk the mother's breasts make. That's why recommendations to rigidly schedule and limit feedings or to never breastfeed at night (instead of responding to a nursling's cues for frequent, flexible feedings) can result in a reduced milk supply. It's also why nursing more frequently and ensuring that a nursling is effectively draining the breast are good first steps toward increasing milk supply.

Sometimes the misinterpretation of a nursling's behavior can lead mothers to think they don't have enough milk even though they actually do. Let's say a baby seems fussy after a feeding. The mother-or someone around her-may interpret the baby's behavior to mean that the mother doesn't have enough milk. A mother can have plenty of milk, but if she is engorged, the baby isn't positioned and latched on well, or the baby is using an incorrect suckling pattern because of exposure to artificial nipples, then the baby may not nurse effectively. (Such problems have solutions: they do not have to result in low milk supply or weight loss in a baby.) Or perhaps the mother has plenty of milk and the fussy baby is nursing effectively, but has thrush (an oral yeast infection) or is teething or needs to have a bowel movement. Fussiness can even be due to an ample milk supply that flows so quickly the baby has difficulty managing its abundance! These are just a few of the many reasons a baby might be fussy at the breast and that might lead to someone suggesting that a mother supplement with formula. Regardless of what leads to supplementation with formula, it is a very effective way of decreasing a mother's milk supply if her breasts are emptied less frequently and thoroughly because of it. Remember: milk supply follows the law of supply and demand.

Before or after the birth of a baby, International Board Certified Lactation Consultants and La Leche League Leaders can help mothers sort through breastfeeding advice to identify what is helpful and what might get in the way of building and maintaining a good milk supply. They can help mothers learn about positioning and latch-on so that nurslings can effectively obtain milk, how to tell a nursling is getting enough milk, and how to increase milk supply, if needed. They can also refer mothers to healthcare providers to evaluate a nursling's weight gain and development or to determine if there are any physiological causes of low milk supply in mother (e.g., a hormonal imbalance, retained placenta, previous breast surgery) or nursling (e.g., tongue-tie, low muscle tone, respiratory problems)-many of which are treatable.

I'm currently tandem nursing my 28-month-old daughter and 3-month-old son. While I think the overall experience is valuable I find it very exhausting. My daughter asks to nurse about every 20 minutes. When I try to distract or set limits it puts her into horrible fits. I feel impatient with the baby when he is nursing because I'm so touched out. How can I set reasonable limits for my toddler? And what is reasonable?

Whether or not a mother is tandem nursing, mothering two young children takes a great deal of time and energy. Feeling "touched out" is understandable when your children currently need so much physical contact with you. Ambivalence about any aspect of mothering is common and normal. We can value the overall experience highly and still feel impatient with our children's intense need for us-especially if what we feel able to provide seems very different from what our children need at that moment.

Figuring out the reason or reasons behind your daughter's frequent nursing can be helpful in creating a process of change. For example, at the age of 28 months, any child is likely to need frequent comforting and reminders of security as she learns to manage the excitement and challenges that come with her ongoing development. Breastfeeding is often an effective means of soothing the bumps, bruises, frustrations, fears, and fatigue of young children. Another possibility might be that your daughter is seeking comfort and healing at your breast because of illness, allergy, or the eruption of a second year molar. (A breastfeeding-knowledgeable health care provider can help you sort through possible health issues.) Of course, the arrival of a new baby requires lots of learning and adjusting by everyone in a family. Frequent nursing may help your daughter feel reassured that she is loved now just as much as when she was an only child. In addition to the arrival of your new baby, your daughter might be reacting to something else going on in the family: a change in routine, a recent move, a family conflict, etc. And, there might be other reasons for her frequent breastfeeding besides the ones I have mentioned here.

Your desire to put limits on her frequent nursing is understandable: it is difficult to feel exhausted and impatient so much of the time. Your question-"And what is reasonable?"-shows your sensitivity to your daughter's needs even while you are struggling with these challenges. Your needs, your baby's needs and your daughter's needs are all legitimate. "Reasonable limits" are arrangements that let each of you get your needs met as much as possible. At times, breastfeeding may seem to be the only way to fully meet a need that your daughter has. At other times, another option might seem to meet a need quite well. The challenge, of course, is to figure out what those needs are and what those options might be ahead of time! The more proactive you are able to be, the less need there may be for limit setting. And the fewer limits you set, the more responsive your daughter may be able to be those limits. As you work toward arrangements in frequency, duration, and positioning that work for all three of you, you might find some of these approaches helpful. I hope there's something here that you haven't already tried!

Options that might decrease the frequency of your daughter's requests to nurse:

1. Increase the time you and your daughter spend with other people: set up play dates, go to the park, invite friends or relatives over or go to visit them, share family time with your partner at home, participate in a breastfeeding support group, etc. Many mothers living in Western and Westernized societies spend their days in a great deal of isolation. Independence is highly valued. So, many of us feel like we should be able to handle everything all by ourselves. In reality, mothers need a great deal of support and companionship: we weren't meant to mother alone. To obtain support, some mothers intentionally create their own "tribe," being with other mothers (and their children) to share the work of cooking and nurturing, giving each other opportunity to take a much-needed nap, etc. Other people can help meet our children's legitimate-and often intense-needs for physical, emotional, and mental interaction. Many young children nurse less frequently when they are on an outing or around additional people. So, you may find that more time spent with others means less frequent nursing, less feeling touched out, and more resources for mothering and tandem nursing.

2. Provide your older nursling with easy access to healthy snacks and good things to drink. Little ones need to eat and drink frequently whether by breastfeeding or by consuming table foods and drinks-and some children need this even more frequently than others to feel well and to function well. If your daughter always has snacks and drinks within reach, she might be less hungry and thirsty for breastfeeding.

3. Give your daughter plenty of cuddles, kisses, attention, and opportunity to use her expanding capacities and skills. Inviting her frequently to do projects and activities with you might help meet her need for interaction with you without it always having to be through breastfeeding. For example, you can ask for her help with small tasks in the kitchen, around the house, or in caring for the baby. Or, you can draw with her, take a bath together, teach her a new game or song, take a walk together, etc. Wearing your baby in a sling or other soft carrier can allow you to have your hands free for a project or activity with your daughter.

4. For a day or two, try offering to nurse your daughter frequently-before she even asks. If she's been feeling insecure since the birth of her little brother, your frequent offering might help her understand that you truly do continue to love her just as much as before. If that's what the frequent breastfeeding has been all about, frequent offering might paradoxically result in less frequent nursing.

5. Breastfeed your baby in a sling so that your daughter is less aware of when you are nursing him. She might ask to breastfeed less because she has fewer reminders.

Options that might help you feel more comfortable with nursing:

1. Use deep breathing, imagery, or other relaxation techniques whenever you feel impatient while breastfeeding.

2. Do something while nursing that makes the time seem to go faster or more pleasantly for you: read, listen to the radio or to your favorite music, eat or drink something, etc.

3. Nurse while lying down so that you get more rest to cope with the needs of your two young children.

4. Experiment with breastfeeding your children at the same time. If this works for you and your children, even some of the time, it can reduce the overall time you spend breastfeeding each day.

5. Remember that nursing is one way (but not the only way) to show your older child that you continue to love her-and the baby in her-even though she's now a big sister. She doesn't have to be a "big girl" all the time, until she is ready.

6. Take stock of your own self-care: nutrition, rest, support, health, etc. I have never met a mother of young children who finds engaging in self-care easy or who feels that she accomplishes enough of it. Taking care of yourself is not selfish under any circumstances. You can't pour water from an empty bucket.

Options that might help you set limits with nursing:

1. Figure out which circumstances of your daughter's nursing feel the most problematic to you. Work on them first. If you are able to create a better arrangement for the most challenging one or two circumstances, you might feel much better about the other times your daughter asks to breastfeed.

2. Try telling your daughter that she can nurse while you sing a favorite song or tell a short story to her. Some nurslings and mothers find this technique works well: the child gets her need to nurse met, the mother gets her need to shorten the time spent breastfeeding met, and the mother does something while nursing that distracts her from her sense of impatience.

3. Share toys with several families so that you always have something "new" to play with that might engage your older child's attention longer than the toys she's already mastered. When you're feeling especially "touched out," you might try bringing out something "new" for her to play with, saying something like this: "Yes, we can nurse, honeyA?. Oh, I just remembered that I haven't shown you this new toy/project/activity. Would you like to see it?" She might not even experience this type of response as limit setting.

4. When faced with limits on breastfeeding (or anything else), young children may feel very strong emotions. Many toddlers respond better when their desire to nurse (or do anything else) and their frustration at the limit are acknowledged. For example: "I can see you really want to nurse right now, sweetheart. It's so frustrating to be asked to wait until after Mommy finishes breakfast. You really want to nurse right now, don't you? We'll be sure to nurse as soon as I'm done." Holding firm to a limit that is important to you can still be done with empathy for your child's experience of that limit. When a child feels understood, she is often able to get through the difficult moment sooner and more comfortably than when she is simply told "no."

5. Remember that breastfeeding does not have to be all or nothing. Many mothers and children have found partial weaning to be a good option. Breastfeeding can be limited to certain times of day, circumstances, or locations. More ideas can be found in How Weaning Happens by Diane Bengson and Mothering Your Nursing Toddler by Norma Jane Bumgarner (see bibliography below). Many La Leche League Groups include these books in their library collections for mothers to borrow. Both books are available from La Leche League International.

I encourage you to get support from other mothers who have experience with tandem nursing. You can go to a La Leche League meeting or call up a La Leche League Leader and ask for suggestions. You might have several experienced mothers nearby who can share how they handled things and who can help you brainstorm more ideas that might work well for you and your family.

Bibliography
Bumgarner, N. J. Mothering Your Nursing Toddler. Schaumburg, IL: La Leche League International 2000.

Bengson, D. How Weaning Happens. Schaumburg, IL: La Leche League International 1999.

Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.

Pitman, T. Finding your tribe: Feed your soul while feeding your kids. Mothering. 102:72\'9677. Online at: www.mothering.com/9-0-0/html/9-5-0/finding-your-tribe.shtml

I am three months pregnant and still breastfeeding my almost two year old. My doctor says I need to wean him because lactation takes nutrients away from the baby. I don't want to wean. Is this true?

Many women are advised to wean when they become pregnant because of concern that the unborn baby will be inadequately nourished. However, two studies cited in The Breastfeeding Answer Book show other evidence (Mohrbacher & Stock 2003). The study by Moscone and Moore (1993) found the babies of 57 mothers who breastfed during pregnancy to be healthy and the appropriate weight when they were born. In another study of 253 women conducted by Merchant and others (1990), no significant differences were found in the birth weight of babies when mothers who weaned an older sibling more than six months before conception were compared with mothers who breastfed into the second or third month of pregnancy. The women in this study who continued breastfeeding during pregnancy were noted to have taken more of the nutritional supplements made available to them and to still have shown evidence of reduced maternal fat stores. Mothers who breastfeed during pregnancy can ensure that they are eating nutritious foods, gaining weight as recommended, and resting adequately. They can consider taking prenatal vitamins as a precaution and consuming extra calories. If a mother is eating well, breastfeeding during pregnancy will not deprive the unborn child of needed nutrients (Mohrbacher & Stock 2003).

References
Merchant, K., et al. Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals. Am J Clin Nutr 1990; 52:280-288.
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003, p. 407.
Moscone, S. and Moore, J. Breastfeeding during pregnancy. J Hum Lact 1993; 9(2):83-88.

I was recently on a large dose of antibiotics for 20 days and also received 4 antibiotic injections. I have not noticed any type of yeast infections (including nipples), yet I noticed what could be thrush on my baby's tongue today. It is very difficult to see because it is far back on the tongue (like where my nipple would be when eating). What do I do about treating him for thrush-and me for an unseen yeast infection? And how do I go about doing it so we don't keep passing it back to each other in the process?

Thrush is an overgrowth of the yeast Candida albicans that is naturally present in the human body. No conclusive medical test exists that can confirm thrush. It is basically a diagnosis of exclusion that is made when all other causes of the symptoms have been ruled out. Possible symptoms of thrush in a nursling do include white patches in the mouth and on the tongue. If these white patches are wiped off they may look red or may bleed. Other symptoms in the nursling may include: diaper rash, a whitish sheen to the saliva or the inside of the lips, repeated pulling off of the breast, clicking sounds during nursing, breast refusal due to a sore mouth, gassiness, fussiness, and (rarely) slow weight gain (Mohrbacher & Stock 2003).

Any time a mother suspects her baby has developed thrush, she should contact her healthcare provider for medical care. Both mother and baby will need to be treated simultaneously as thrush can be passed back and forth between mother and nursling, even if only the nursling is showing visible symptoms. Many treatments for overgrowth of yeast exist, including suspensions and oral gels for the nursling, and creams, ointments and systemic treatments for the mother. If your healthcare provider is not familiar with the treatment of thrush, you can refer him or her to The Breastfeeding Answer Book which provides information on a several over-the-counter and prescription medications.

Techniques for preventing the spread of thrush to other family members and for preventing reinfection after treatment include:

• Frequent and careful hand washing for all family members, including nursling
• Boiling breast pump parts that touch milk, as well as pacifiers, bottle nipples, and teething rings once a day for twenty minutes
• Changing breast pads with each feeding, discarding disposable breast pads after each feeding, and washing cloth breast pads in hot, soap water before reusing
• Washing toys that come in contact with the baby's mouth in hot, soap water, then rinsing well
• Washing clothing and towels that come in contact with yeast in very hot water (above 50A?A^??q C or 122A?A^??q F)
• Wearing a clean bra every day (Mohrbacher & Stock 2003).

• Taking acidophilus bifidus, grapefruit seed extract, garlic tablets, zinc and B vitamins
• Reducing the consumption of dairy products and sugar
• Drinking more water
• Ruling out anemia and diabetes via medical tests (Mohrbacher & Stock 2003).

References
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003, pp. 480-483.
Wilson-Clay, B. and Hoover, K. The Breastfeeding Atlas. Austin, Texas: LactNews Press 2002, pp. 54-62.

Due to numerous problems even with the help of lactation consultants, I was unsuccessful and stopped breastfeeding at 10 weeks. My daughter has been having a rough time with formula so I am currently using a close friend's breastmilk and she is doing so much better with that. I have done some research on relactating and hear stories that adoptive women can even make milk. How realistic would it be to relactate when my daughter is now 7 1/2 months old? What would the process be? Would I need medications or herbs? Do you know women who have successfully done this at her age?

It sounds as though you faced many challenges with the initiation of breastfeeding in spite of your best efforts. Though I cannot predict your personal likelihood of being able to relactate (stimulating a milk supply after ceasing breastfeeding for a time), I can tell you that women have successfully relactated or induced lactation (stimulated a milk supply without having been pregnant) for adopted infants close in age to your daughter - and older. (For one example, see the article Nursing Julia: My Supreme Challenge, by Darillyn Starr at.) Approaches to relactation vary based on mothers' preferences and the options and support available to them. Some women use galactagogues (herbal or prescription medications known or believed to increase milk supply); some do not. Each mother's response to breast stimulation varies depending on her personal body chemistry (Mohrbacher & Stock 2003, p. 397). Strategies for relactation include (but are not limited to):

• Breastfeeding at least eight to twelve times per day (every one and one-half to two hours during the day and at least every three hours at night).
• Making sure that the baby latches well and is positioned well during breastfeeding.
• Offering both breasts at each feeding.
• Letting the baby finish the first breast first and not arbitrarily limiting the length of feeding (so that the baby gets the higher calorie milk available in an emptier breast).
• Using breast compression during feedings whenever the baby seems to not be actively nursing.
• Using a nursing supplementer to allow the baby to receive extra nourishment as well as comfort at the breast.
• Avoiding bottles, pacifiers, swings, and other soothers to maximize the amount of time baby spends at the breast.
• Picking times to nurse that the baby is not too hungry or too sleepy.
• Choosing a comfortable and private place to nurse, free from distractions for baby and mother.
• Providing baby with a lot of skin-to-skin contact and cuddling, along with offering the breast.
• Attempting breastfeeding while the baby is sleeping, if he or she has difficulty breastfeeding while awake.
• Breastfeeding in the bathtub with the baby's body submerged and his or her face above water.
• Approaching breastfeeding sessions as times of closeness and special attention.
• Avoiding feeling pressured about how the baby responds to nursing sessions.
• Considering partially inducing lactation for an older baby or toddler: a partial milk supply may be all that is needed if a baby has already begun eating table foods.
• Using herbal or prescription galactagogues after consultation with a physician.
• If the baby is unwilling or unable to breastfeed, expressing milk 8 to 10 times a day (including the night).
• If the baby is nursing, expressing milk after feedings to drain the breast more completely.
• If the mother is using a breast pump, using a full-size, automatic double pump that provides between 40 and 60 suction-and release cycles per minute.
• If the mother is expressing milk, continuing expressing until two minutes after the last drop of milk is seen.
• If the mother is using a breast pump, double pumping because doing so may increase milk supply than single pumping.
• Resting and eating well so that it is easier to cope with the time and effort that relactation takes.
• Accepting all offers of help so that more time and energy are available to work on relactation (Mohrbacher & Stock 2003, p. 390-398).

I don't know what challenges you faced in your earlier experience with breastfeeding - or whether any of them still exist. For example, an unsupportive social environment may undermine a mother's most vigorous efforts to breastfeed - and to relactate. A mother might have difficulty developing an adequate milk supply because the baby is tongue-tied and cannot effectively empty the breast. Breastfeeding may be painful and difficult because the baby has a high palate. A mother might have had breast surgery or injury to her breast or inadequate glandular development that has decreased her ability to fully breastfeed. A hormonal imbalance may need to be treated in order for breastfeeding to be possible. Also, a baby's ability to take the breast and suckle effectively varies with age, interest, adaptability, distractibility, basic temperament, and previous feeding experience (Mohrbacher & Stock 2003, p. 397). Identifying and addressing such factors are important steps in relactation.

As far as breastfeeding management goes, your situation is similar to that of a mother who has adopted a baby and would like to breastfeed. Therefore, adoptive breastfeeding resources may be useful to you. Resources published by LLLI and/or available from the LLLI catalogue include:

• Can I Breastfeed My Adopted Baby? a section in LLLI's online collection of Frequently Asked Questions.
• Adoptive Breastfeeding, a collection of links to online articles by mothers who describe their experience with adoptive breastfeeding. The articles are reprinted from New Beginnings, LLLI's journal for breastfeeding mothers.
• Breastfeeding the Adopted Baby (revised edition) by Debra Stewart Peterson. This book offers a step-by-step description of the process of inducing lactation in a woman who has not given birth.
• Nursing Your Adopted Baby, a 22-page pamphlet by LLLI providing information on bonding and attachment, building a milk supply, supplementing, and finding a support system.
• The Breastfeeding Answer Book by Nancy Mohrbacher and Julie Stock (2003). This book offers detailed information on relactating, inducing lactation, increasing milk supply, encouraging a baby to take the breast again, and coping with a wide variety of breastfeeding challenges.

Another issue to consider is whether an inadequate level of experience or training of the "lactation consultants" who worked with you could have contributed to your initial breastfeeding challenges. Many mothers do not know that anyone can call him- or herself a "lactation consultant," a "lactation specialist," a "breastfeeding counselor," etc. Some people holding such titles may not have enough training or experience to be fully effective. The title is completely unregulated. However, only people who have qualified to take and have passed the exam of the International Board of Lactation Consultant Examiners are entitled to call themselves "International Board Certified Lactation Consultant" (IBCLC). For more information on that certification and to find an IBCLC near you, see the website of the International Board of Lactation Consultant Examiners at: http://www.iblce.org. Other sources of breastfeeding support and information are La Leche League (LLL) Leaders. These women are experienced breastfeeding mothers who have been trained and accredited by La Leche League International. They are backed up by an extensive support system from which they can seek more information whenever it is needed. To find an LLL Leader near you, see the website of La LecheLeague International.

Asking about the credentials, training, and experience of lay or professional breastfeeding counselors is always appropriate. You have the right to request a referral to someone more experienced if the people working with you are not able to effectively help you. And, regardless of their credentials, lay or professional breastfeeding counselors or other healthcare providers should never let themselves be the last stop for a mother trying to overcome breastfeeding difficulties. The odds are good that the situation is not entirely unique and that someone out there has more information on and/or experience with it.

Best wishes to you and your baby, whatever decisions you make!

References
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.
Starr, D. Nursing Julia: My Supreme Challenge. New Beginnings 1993; 10(5):135-136.

Could a breastfed baby negatively react to mother's milk if mother is eating foods which baby may be allergic to (e.g., milk/lactose), or other foods like caffeine or sugar?

It is unusual for a baby to be sensitive to a food or other substance that his or her mother ingests. Most mothers can eat any food without their breastfed baby experiencing any problem. Interestingly, different cultures create different lists of foods that a mother should and should not eat: what is considered a problem in one culture may be encouraged in another! In addition, most medications are not contraindicated during breastfeeding, in part, because many of them pass into the mother's milk in only very small amounts. However, some babies are more sensitive than others and may react negatively to a medication, vitamin, caffeine (in beverages or over-the-counter medications), beverage, or food that the mother is ingesting.

The symptoms of food sensitivity include:

• fussiness during and/or after feedings
• inconsolable crying for long periods
• sleep disturbances
• sudden waking with clear discomfort
• diarrhea, vomiting, green stools with mucus,
• dermatitis, hives, rash, eczema, dry skin
• runny nose, congestion
• coughing, wheezing
• bloody stools (Mohrbacher & Stock 2003)

When a baby reacts to a food in the mother's diet, his or her family may have a history of allergies. The baby has a 30 percent chance of developing allergies when one parent has allergies and a 60 percent chance when both parents have allergies (Vonlanthen 1998). Cow's milk (including many of its individual ingredients, such as cow's milk protein) is the most common cause of food sensitivities and fussiness in babies (Mohrbacher & Stock 2003). Other foods that may cause allergic symptoms in babies include soy, egg white, peanuts, fish (especially cod), wheat, nuts and Kola nuts, corn, pork, citrus fruits, berries, tomatoes, and spices (Riordan & Auerbach 1999, p. 657). Allergens can be hidden in minute amounts in processed foods, even occurring as (unlabeled) cross contamination during food processing (Vonlanthen 1998). The article, Allergies and the Breastfeeding Family, by Karen Zeretzke is a good starting place for a mother wondering if her breastfed baby is reacting to something in the maternal diet. It can be read online from the website of La Leche League International at: www.lalecheleague.org/NB/NBJulAug98p100.html

If a mother consumes more than five 5-oz cups (750 ml) of caffeinated coffee in a day (or an equivalent amount of caffeine from other sources), caffeine could start to accumulate in the baby's system, resulting in a wide-eyed, active, alert baby who doesn't sleep for long and may be unusually fussy (Mohrbacher & Stock 2003). If caffeine is the reason for the baby's fussiness, he should be feeling better within a few days to a week after his mother is no longer consuming caffeine.

Lactose is the primary carbohydrate contained in human milk (Riordan & Auerbach 1999, p. 128). Even though mothers of fussy babies with frequent watery stools are often told that their babies may have lactose intolerance, it is actually unlikely (Lawlor-Smith and Lawlor-Smith 1998). Congenital lactose intolerance in babies is rare (Mohrbacher & Stock 2003; Riordan & Auerbach 1999, p. 129). Sometimes lactose intolerance develops in babies because of damage to the lining of the small intestine during illnesses (e.g., allergy or intolerance, gastroenteritis, or celiac disease). This damage reduces the presence of lactase, the enzyme that converts lactose into simple sugars that can be easily assimilated (Riordan & Auerbach 1999, p. 129). When the underlying problem is addressed and the intestine heals, adequate lactase is again available and the baby no longer has difficulty digesting lactose. Babies can also have difficulty digesting lactose because they aren't obtaining enough of the higher fat milk available in an emptier breast. A baby can consume too little fat when the mother's supply is greater than the baby's demand (oversupply). The proportion of fat changes with breast emptiness: the emptier the breast, the greater the fat content (Riordan & Auerbach 1999, p. 129). Fat slows down gastric emptying, enabling better digestion (Mohrbacher & Stock 2003). Changing how breastfeeding is managed-so that the baby obtains more fat-offers relief from the symptoms of too much lactose. For example, if she has not already been doing so, a mother could try letting the baby finish the first breast first before offering the second breast. If the mother has been limiting the time a baby can nurse (e.g., 10 minutes on each breast), she can try following the baby's cues for when to switch breasts. If her baby is gaining well and the mother has an oversupply of milk, she can try offering one breast for a few feedings before switching breasts whenever the baby wants to nurse again within two hours (Mohrbacher & Stock 2003, p. 126).

La Leche League Leaders and International Board Certified Lactation Consultants can provide still more information on allergies, sensitivities, intolerances, and oversupply, including a variety of ways of coping with such situations. There are lots of tools in the toolbox!

References

Lawlor-Smith, C. and Lawlor-Smith, L. Lactose intolerance. Breastfeed Rev 1998; 6(1):29-30.

Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.

Riordan, J. and Auerbach, K. Breastfeeding and Human Lactation. Boston, MA: Jones and Bartlett 1999.

Vonlanthen, M. Lactose intolerance, diarrhea, and allergy. Breastfeeding Abstr 1998; 18(2):11-12. Online at: www.lalecheleague.org/ba/Nov98.html

Zeretzke, K. Allergies and the breastfeeding family. Leaven Jul-Aug 1998; 15(4):100.

Do you know of any milk banks? Any idea of the cost? Any recommendations for healthy formula? A mom I know just adopted one baby and found another is on the way. She is attempting to lactate, but realistically will have to supplement and is leery of cowA?A^-s milk, soy, and corn formulas due to allergy/hormone issues. Any good adoptive nursing resources you can suggest, aside from LLL, which has been great?

You ask many good questions! Fortunately, information about adoptive nursing and related issues is more available today than ever before. Let's start with the risks of formula or why acquiring donor milk from a milk bank is an option well worth investigating if an infant needs supplementation.

Human milk contains ingredients "that cannot be duplicated in a factory because breastmilk is a living biological fluid; it contains, for example, hormones, active enzymes, growth factors, immunoglobulins, anti-inflammatory components, cytokines (involved in immune function), and other compounds with unique structures. These special ingredients allow breastmilk to stimulate and support the maturation of the nursling's immune system, as well as the growth and maturation of other organ systems. The amount and type of nutrients, growth factors and immunological components of breastmilk continually change in response to the dynamic needs of the nursling so that the contents of each mother's milk varies during a feeding, in the course of a day, and throughout the duration of breastfeeding." (Michels, Good Mojab, & Bar-Yam 2001). In addition, the bioavailability (the amount of a nutrient that the body can actually absorb) of ingredients in formula (e.g., calcium, iron) is significantly less than it is in human milk. A wealth of research has shown that many health risks are increased with formula feeding. For example, formula-fed infants have a higher incidence of illness, allergies, childhood cancer, juvenile diabetes, obesity, and Sudden Infant Death Syndrome than do breastfed infants (Michels, Good Mojab, & Bar-Yam 2001).

In light of these health risks, the United Nation's Children's Fund (UNICEF) and the World Health Organization (WHO) prioritize feeding options for babies, in decreasing order of preference as follows: being directly breastfed by the mother, being fed milk expressed from the mother's breasts or from another healthy mother, and, lastly, being fed a substitute for human milk (UNICEF 2002). The selection of a formula should be made in consultation with a physician (Mohrbacher & Stock 2003). If, at any point, a mother's milk supply is not adequate, the bottom line is always: feed the baby. A mother will decide how best to do this based on her personal circumstances, including the information, support, and options available to her. This particular mother's circumstances include the fact that she is pregnant. An established milk supply naturally decreases in amount and changes in flavor during the second trimester of pregnancy as the mother's breasts prepare to produce colostrum; even if a mother starts pregnancy with a full milk supply, the decrease may compromise the nutritional needs of a nursling younger than a year old and necessitate supplementation (Mohrbacher & Stock 2003). Once her second child is born, she has the option of initiating breastfeeding as though she is trying to develop a milk supply adequate for twins. (See below for resources offering information on how to do this.) And, remember: there is more to breastfeeding than nourishment. Regardless of the amount of human milk a nursling receives, breastfeeding is a relationship, a form of nurturing, and a way of mothering.

At the time of this writing (June 20, 2003) the website of the Human Milk Banking Association of North America (HMBANA) lists the contact information for seven donor milk banks. The American milk banks are located in: Denver, Colorado; Austin, Texas; San Jose, California; Raleigh, North Carolina; Iowa City, Iowa; and Newark, Delaware. The Canadian milk bank is located in Vancouver, British Columbia. According to Mary Rose Tully, MPH, IBCLC, Immediate Past Chair, HMBANA, for several milk banks, the charge for processing and shipping donor milk is about $3.50 per ounce, but some banks charge $4.00 per ounce. Donor milk is dispensed only on physician order. There is a priority list when milk is in short supply. However, when milk is plentiful, healthy, adopted babies and babies who for other reasons cannot breastfeed can be dispensed donor milk. Also, the milk banks collaborate. So if one bank is short and another has sufficient supplies, the recipient is referred to another bank. But, this always occurs with an order from the baby's physician. There is a triaging algorithm in the guidelines for times of short supply. It basically requires that milk first be provided to the sickest recipient for whom donor milk will have the biggest impact." If the mother wants to acquire donor milk from a milk bank, a good first step is to find a pediatrician who is knowledgeable about breastfeeding and the importance of human milk. If the mother lives outside of North America, she can ask her babies' physician for help finding a milk bank near her. Another good step is to contact a La Leche League Leader and International Board Certified Lactation Consultant for help in developing her milk supply and managing the breastfeeding of two babies.

La Leche League International (LLLI) has many resources on adoptive breastfeeding. It seems you have already accessed at least some of them. But, just in case you aren't familiar with all of them, I have listed several below. The mother might also find information about nursing twins or tandem nursing useful, given that her two babies will be close in age. Relevant resources published by LLLI and/or available from the LLLI catalogue at www.lalecheleague.org/catalog.html include:

Can I Breastfeed My Adopted Baby?, a section in LLLI's online collection of Frequently Asked Questions www.lalecheleague.org/FAQ/adopt.html

Adoptive Breastfeeding, a collection of links to online articles by mothers who describe their experience with adoptive breastfeeding. The articles are reprinted from New Beginnings, LLLI's journal for breastfeeding mothers www.lalecheleague.org/NB/NBadoptive.html

Breastfeeding the Adopted Baby (revised edition) by Debra Stewart Peterson. This book offers a step-by-step description of the process of inducing lactation in a woman who has not given birth

Nursing Your Adopted Baby, a 22-page pamphlet by LLLI providing information on bonding and attachment, building a milk supply, supplementing, and finding a support system. Mothering Multiples: Breastfeeding and Caring for Twins or More! by Karen Gromada. This revised edition discusses all aspects of mothering multiple babies including establishing a milk supply for multiple babies.

Nursing Two, Is It For You? Tandem Nursing, a 20-page pamphlet answering the questions about breastfeeding two children at the same time, how to get started, and simultaneous feedings.

Adventures in Tandem Nursing by Hilary Flower (2003). This book provides in-depth answers to a wide range of questions related to breastfeeding during pregnancy and tandem nursing.

The Breastfeeding Answer Book by Nancy Mohrbacher and Julie Stock (2003). This book offers detailed information on inducing lactation, increasing milk supply, breastfeeding multiples, tandem nursing, and methods of supplementation.

The Womanly Art of Breastfeeding, published by La Leche League International, contains information on adoptive breastfeeding, tandem nursing, and nursing multiples, among many other breastfeeding topics.

The mother might be able to borrow some or all of these publications from her local La Leche League Group library and/or her local public library. In addition, the adoptive breastfeeding mothers with whom I have worked report that the Adoptive Breastfeeding Resource Website contains information they found to be helpful. It also offers discussion boards where adoptive breastfeeding mothers can connect. The mother might find that other adoptive breastfeeding mothers are a welcome source of information and support. She can ask if her local La Leche League Leader or International Board Certified Lactation Consultant can help her find mothers in her own community who have experience with any aspect of her situation, be it adoptive nursing, tandem nursing, or nursing multiples.

References

UNICEF. Facts for Life. New York: UNICEF, WHO, UNEFSCO, UNFPA, UNDP, UNAIDS, WFP, and the World Bank 2002.

Michels, D., Good Mojab, C., and Bar-Yam, N. Breastfeeding at a Glance: Facts Figures and Trivia about Lactation. Washington, DC: Platypus Media 2001.

Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.

I'm 6 weeks pregnant and I am still nursing my 2 year old. My husband is nervous and scared because I was pregnant last year and had a miscarriage at 3 months. Could breastfeeding my 2 year old provoke another miscarriage?

I am sorry for your loss. Your husband's concern and your question are both understandable. When miscarriage occurs, many mothers and fathers want to understand why it happened, in part, so that any identifiable causes can be avoided in a subsequent pregnancy. About one in five pregnancies end in miscarriage and the cause is often not known (Kitzinger 1994; p.339-340). While feelings of fear and guilt are common among parents who have experienced a miscarriage, there is rarely anything anyone could have done to prevent it from happening (Kohn, Moffitt, and Wilkins 2000, p. 10).

As of the writing of the third edition of The Breastfeeding Answer Book (published in January 2003), no studies have investigated the effect of breastfeeding during pregnancy on the outcome of pregnancy (Mohrbacher & Stock 2003, p. 407). This lack of research is reflected in the fact that there is no medical consensus regarding when breastfeeding during pregnancy may pose risks; health care providers may recommend weaning if a mother experiences uterine pain or bleeding, a history of or signs of threatened preterm labor, and/or difficulty gaining enough weight during pregnancy (Mohrbacher & Stock 2003, p. 408). Mild contractions (known as Braxton-Hicks contractions) are a normal part of pregnancy whether or not a mother is breastfeeding (Flower 2003, p. 225).

In spite of a lack of evidence that breastfeeding increases the risk of pregnancy loss or premature labor, many healthy pregnant mothers with normal pregnancies are advised by health care providers to wean and may face criticism if they continue to breastfeed during pregnancy (Riordan & Auerbach, p. 332). However, the American Academy of Family Physicians states, " Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman's personal decision. If the child is younger than two years of age, the child is at increased risk of illness if weaned. Breastfeeding the nursing child after delivery of the next child (tandem nursing) may help to provide a smooth transition psychologically for the older child." (AAFP 2002). According to Mohrbacher and Stock (2003, p. 407), "Uterine contractions stimulated by breastfeeding usually pose no danger to the unborn baby and do not increase the risk of premature delivery." Riordan and Auerbach (1999, p. 332) state, "In most cases, breastfeeding will not affect the fetus in any way, and there is no evidence that uterine contractions are associated with fetal loss."

Finally, in her book Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond, Flower (2003, pp. 225-228) reviews research and clinical findings related to breastfeeding, uterine contractions, and pregnancy. The hormone oxytocin is released during breastfeeding, causing milk to be "let down" or ejected from the breast. This hormone also causes the uterus to contract. However, these contractions are usually mild during pregnancy if mothers report feeling them at all. Furthermore, the uterus is not very responsive to oxytocin for most of pregnancy. After 37 weeks, its responsiveness increases slowly. After labor has begun, the responsiveness of the uterus to oxytocin increases dramatically. Flower (2003, p. 234) summarizes: "At this point there are valid reasons to doubt that breastfeeding adds to the risk of miscarriage or preterm labor in healthy pregnancies. Studies have shown that cells known as oxytocin receptors on the uterus do not mature and become active until late in pregnancy when the baby is ready to be born. This is consistent with the many anecdotal and documented reports of mothers breastfeeding throughout pregnancy and giving birth at term to healthy babies."

The decision to continue breastfeeding or to wean during pregnancy is an individual one. A breastfeeding-friendly health care provider can help you apply the available research to your particular situation. I hope that the information here will help you make an informed decision that you and your husband feel confident about and comfortable with. Best wishes to you and your family.

I have been diagnosed with post-partum depression. My estrogen level is extremely low. I am 42 years old and breastfeeding a 6-month-old. My doctor says that my low estrogen is not a result of breastfeeding or my age. He has prescribed an estrogen cream. Will it interfere with my milk production?

Dr. Thomas Hale's book, Medications in Mothers' Milk, provides information on the use of a wide variety of medications during lactation, including prescription estrogens such as Estratab, Premarin, Menest, Delestrogen, Estinyl, Estrace, Estraderm, Estring, and Evorel (Hale 2002, pp. 258-259). According to Dr. Hale (2002, pp. 258):

"Although small amounts may pass into breastmilk, the effects of estrogens on the infant appear minimal. Early post-partum use of estrogens may reduce volume of milk produced and the protein content, but it is variable and depends on the dose and the individual.1-4"

Dr. Hale (2002) considers estrogens to be "moderately safe" during lactation, stating that:

"There are no controlled studies in breastfeeding women, however the risk of untoward side effects to a breastfed infant is possible; or, controlled studies show only minimal non-threatening adverse effects. Drugs should be given only if the potential benefit justifies the potential risk to the infant."

Also, I asked Dr. Hale about estrogen levels and estrogen when a 42-year-old woman is breastfeeding a six-month-old baby. Dr. Hale stated, "Estrogen levels are relative. They depend on the individual mother, her age, her state of lactation, the laboratory that tests the levels, and other factors. It is quite well known clinically that exogenous estrogens can produce major reductions in the milk supply of some mothers. It totally depends on the individual mother."
(personal communication, August 19, 2003).

If you choose to use the estrogen cream, you can monitor your milk supply by looking for changes in your baby's output: fewer wet diapers and bowel movements would be indicators that your baby is taking in less of your milk than before, especially if your baby is exclusively or nearly exclusively breastfed. If your baby is consuming many foods and liquids away from your breast, you may have to check to see whether changes in his or her pattern of eating table foods is the cause of changes in output. Weight gain that slows down or stops or your baby suddenly being discontent at the breast would also suggest the possibility of a decrease in your milk supply. However, fussiness at the breast can also be caused by factors other than a low milk supply. If you think your milk supply is decreasing, you can get help from a local International Board Certified Lactation Consultant or La Leche League Leader to monitor and rebuild your supply if needed. Milk production is a very dynamic process.

You can discuss with your doctor alternatives to the current plan of treatment if you do not wish to use the estrogen cream or if your milk supply decreases while using the estrogen cream. Also, many breastfeeding-compatible options are available for treating post-partum depression. I have included some resources below that can provide more information on estrogen, post-partum depression, and women's health issues, such as perimenopause.

It can be challenging to make informed decisions about the use of maternal medications while breastfeeding. Discovering all of the options may not be a quick or easy process. Both mothers and physicians may think that the hormonal state of breastfeeding is causing the post-partum depression and/or that the pharmacological treatment of depression contraindicates breastfeeding. However, the hormonal state of breastfeeding is the biologically normal hormonal state of women following pregnancy. And it is their biologically normal hormonal state for quite some time: anthropologist Dr. Katherine Dettwyler estimates that, if culture didn't tell us to do otherwise, the natural age of weaning would average between 2.5 and 7 years of age (Dettwyler 1995, p. 39). According to Boyle (1993):

"The safety of prescription medication is of great concern to mothers. Weaning is often advised by physicians who may feel the woman's emotional state is aggravated by the hormones produced by lactation. Some doctors believe that a quick return to the pre-pregnancy hormonal state facilitates recovery from PPD. However, little attention is paid to the effect on the infant, and consequently, on the mother's relationship with her baby. Sometimes a mother who is depressed may believe that breastfeeding is causing her problem. Although some studies indicate that depression is more prevalent among nursing mothers, these studies don't screen for other factors, such as social isolation or lack of support from family members. Breastfeeding is not a contributing factor to postpartum depression. In fact, the hormonal changes after birth occur more gradually when a mother breastfeeds."

If your physician does not seem to understand the importance of breastfeeding to you or your child, you might consider sharing with him the article, "When Breastfeeding is not Contraindicated," by Jack Newman, MD. In it, Dr. Newman talks about medication issues, including the pharmacological treatment of depression. He concludes:

"Breastfeeding is too important to the child, to the mother, to the family, and to society to sacrifice it as easily as we sometimes do. Health professionals who care about the health of mothers and children should make every effort to avoid interruption of breastfeeding. Breastfeeding can almost certainly continue in most situations, given a belief in its value and a little imagination and ingenuity." (Newman 1997).

I hope that this information helps you make a decision that you feel meets your and your baby's needs. I also hope that you are able to find the support you need as you cope with the very real challenges of post-partum depression. Take care.

References
Boyle, D. Postpartum depression. Leaven July-August 1993; 29(4):53-54, 58

Dettwyler, K. A time to wean: The hominid blueprint for the natural age of weaning in modern human populations. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter 1995.

Hale, T. Medications in Mothers' Milk. Amarillo, TX: Pharmasoft Publishing 2002.

Newman, J. When breastfeeding is not contraindicated. Breastfeeding Abstracts May 1997; 16(4):27-28.

Resources
Specific information about using maternal medications during breastfeeding:

Medications in Mothers' Milk by Thomas Hale, Ph.D., published in 2002 by Pharmasoft Publishing.

La Leche League International's collection of Frequently Asked Questions: "My doctor has prescribed a medication for me. Is it safe for me to continue breastfeeding my baby while I take the medicine?"

"Maternal Medications and Breastfeeding" by Gwen Gotsch, published in 2000 in New Beginnings by La Leche League International.

"Update: Transfer of drugs and chemicals into human milk" by Cheston Berlin, Jr., MD, published in 2001 in Breastfeeding Abstracts by La Leche League International.

General information about medications
Medline Plus Drug Information: A service of the US National Library of Medicine and the National Institutes of Health providing information on a variety of medications

Postpartum depression
"Postpartum Depression" by Denise Boyle, published in 1993 in Leaven by La Leche League International.

The Hidden Feelings of Motherhood: Coping with Stress, Depression, and Burnout by Kathleen Kendall-Tacket, Ph.D., published in 2001 by New Harbinger Publications

Women's health:
(including information on estrogen and perimenopause) Women's Bodies, Women's Wisdom: Creating Physical and Emotional Health and Healing by Christiane Northrup, MD, published in 1998 by Bantam.

I have recently switched my baby to formula. She has been on it for about two weeks. I am beginning to regret that I stopped breastfeeding and would like to breastfeed her again. It has been two weeks since I have stopped. Is it possible to breastfeed again or is it too late? If it is possible to breastfeed again, how do I do it and get her switched back to breast milk?

While I cannot predict your personal likelihood of success, both research and clinical experience show that relactation is possible for more mother-nursling pairs than is commonly realized. For example, in one study of fifteen Indian mothers who attempted relactation after stopping breastfeeding for more than two weeks, all mothers who stopped using a bottle and supplemented using a cup and spoon were successful (Banapurmath, et al. 1993). These mothers breastfed their babies-who ranged in age from 20 days to four months-10 to 12 times per day for 10 to 15 minutes per breast: ten of the mothers achieved exclusive breastfeeding and five achieved partial breastfeeding. Another study of 139 Indian mothers attempting relactation showed that 61 percent were able to fully relactate (including a mother who relactated for twin nurslings) and 23 percent were able to partially relactate (De, et al. 2002). These mothers nursed their babies 10 to 12 times per day for about 10 minutes on each breast. They were encouraged to offer any needed supplements by cup and spoon, to sleep with the baby, and to keep the baby near so as to be able to provide skin-to-skin contact. Still another study of Indian mothers found that 91.6 percent of mothers who had either stopped breastfeeding or were not able to initiate breastfeeding were helped with establishing lactation within 10 days at an outpatient clinic (Banapurmath, et al. 2003). Their babies were less than 6 weeks of age. 83.4 percent of the mothers developed a full milk supply within 10 days; 8.2% developed a partial milk supply within ten days. The researchers concluded that helping mothers with proper attachment at the breast appeared to be crucial for success with relactation.

Approaches to relactation vary based on mothers' preferences and the options and support available to them. Each mother's response to breast stimulation varies depending on her personal body chemistry (Mohrbacher & Stock 2003, p. 397). I have included many strategies for relactation, resources for relactating mothers, and information on additional issues in the fifth question/answer (http://mothering.com/experts/mojab-archive.shtml#relactate) indexed in my archive that I hope you will find useful for your situation.

References
Banapurmath, C., et al. Initiation of relactation. Indian Pediatr 1993; 30(11):1329-32.
Banapurmath, S., et al. Initiation of lactation and establishing relactation in outpatients. Indian Pediatr 2003; 40(4):343-7.
De, N., et al. Initiating the process of relactation: An institute based study. Indian Pediatr 2002; 39:173-78.
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.

I am 31 years old and was recently diagnosed with breast cancer. I will be starting chemotherapy in 3 to 4 weeks. I am currently nursing my 2-year-old and will need to wean him before treatment begins. He has always nursed to sleep and several times in the night. I'm very sad about having to wean him but I don't want the chemotherapy and radiation to harm him. Do you have any suggestions for weaning him gently in this short time frame? Should I use herbs to dry up my supply?

I am very sorry to learn that you have breast cancer. I am also sorry to have to confirm that weaning your son is necessary. Chemotherapy and treatment with radioactive compounds are not compatible with breastfeeding because of their potential to harm the nursling (Riordan & Auerbach, p. 502; Mohrbacher & Stock 2003, p. 533). Since I can't ask you questions in an ongoing conversation, I hope you don't mind my answering more questions than you asked. Because of your sadness about weaning, I especially want to be sure you know that when a mother must undergo chemotherapy and radiation treatment for breast cancer, she can consider permanent weaning or temporary weaning (Mohrbacher & Stock, p. 533). With permanent weaning, the child stops nursing and lactation is permitted to cease. With temporary weaning, the child stops nursing and lactation is protected via expression of milk from the breasts until the mother can safely resume breastfeeding her child. Some women have resumed breastfeeding after a break of as long as three or four months (Mohrbacher & Stock 2003, p. 533). Once treatment has concluded, the radiology department of a hospital or a specialized laboratory can test your milk for radioactivity to determine when the levels have returned to normal and it is safe for you to begin breastfeeding again (Mohrbacher & Stock 2003, pp. 533, 568). Radioactivity is more quickly eliminated from the mother's system when she expresses her milk frequently (Mohrbacher & Stock 2003, p. 533, 568).

If you decide to temporarily wean your son, your body must adjust from its experience of regular breastfeeding to regular milk expression. Milk supply is best maintained when a mother expresses her milk as frequently as her nursling was breastfeeding. And, regardless of your nursling's pattern, milk expression is important any time your breasts feel full or uncomfortable because fullness signals your breasts to slow down milk production. The best method of milk expression depends on the options available to you and your skill at using them (Mohrbacher & Stock, p. 247). For example, many women around the world rely on hand expression and become very effective in its use. Some mothers, however, find it an inadequate method for the long-term maintenance of milk production in the complete absence of breastfeeding. Many women choose to use an automatic electric breast pump with double-pumping attachments when they must exclusively express their milk for a long period of time because it is an effective and quick method. All methods of milk expression require practice to use optimally. What works well for one mother in one situation may work poorly for another mother in another situation. If you should find that treatment makes you too ill or weak to express your milk, you can consider asking someone to help you. Healthcare providers, relatives and friends have helped breastfeeding mothers maintain their milk supply through pumping or hand expression during health crises. If you wish, you can store the milk you express before beginning treatment so that it will be available to your son after he is weaned.

If you decide that you would like to protect your milk supply during treatment, but your healthcare providers are unfamiliar with and unsupportive of temporary weaning in the context of treatment for breast cancer, you may want to talk with them about research on the link between a low lifetime duration of breastfeeding and an increased risk of breast cancer and how that research relates to your risk of recurrence of breast cancer. The Center for Breastfeeding Information at La Leche League International has an online selected bibliography of studies related to breastfeeding and breast cancer at: www.lalecheleague.org/cbi/bibcancer.html. These studies show that the less a woman breastfeeds, the greater her risk for breast cancer. Also, some healthcare providers mistakenly believe that subsequent pregnancy and lactation aggravate the course of breast cancer; research has shown that this is not the case (Riordan & Auerbach 1999, p. 501; Cooper & Butterfield 1970; Peters & Meaken 1965).

A child's ability to relearn how to breastfeed varies with age, interest, adaptability, distractibility, basic temperament, previous feeding experience, and time away from the breast (Mohrbacher & Stock 2003, p. 397). No one can predict now what your son's response would be to the opportunity to nurse again after a temporary weaning. However, women have successfully breastfed younger as well as older adopted infants, including those who have never nursed before. (For one example, see the article, Nursing Julia: My Supreme Challenge, by Darillyn Starr.)

Women who have been treated for breast cancer commonly report that the treated breast (with surgery, radiation, chemotherapy) experiences changes in its ability to lactate after a subsequent pregnancy. These changes include little or no enlargement of the treated breast during pregnancy, lower to absent milk supply, and difficulty with latch-on because of less extension of the nipple (Riordan & Auerbach 1999, p. 501). I did not find mention in the literature of such changes occurring in ongoing lactation when milk supply is protected during treatment and weaning is temporary. Even if they were to occur, breastfeeding can continue partially from the treated breast and partially from the untreated breast or entirely from the untreated breast alone.

If you decide to permanently wean, your body must adjust from its experience of regular breastfeeding to the complete cessation of lactation. However, even if breastfeeding is abruptly stopped, the cessation of lactation does not have to be abrupt. When milk removal is gradually decreased, physical comfort is maintained and the risk of developing plugged ducts, mastitis, or a breast abscess is reduced. A gradual decrease in milk production will also prevent an abrupt drop in a mother's prolactin levels. Prolactin is a hormone that is released during breastfeeding and has been associated with a mother's feeling of well being. Women who are already depressed, are prone to depression, or who have other psychiatric problems may be at risk of the occurrence of or a worsening of depression if prolactin levels drop suddenly (Susman and Katz 1988). When breastfeeding must cease abruptly, these hormonal changes can be made more gradual by the continued use of an automatic or semiautomatic electric breast pump, a manual pump, or hand expression.

Relieving discomfort by expressing a small amount of milk will not encourage a never-ending milk supply. When the amount of milk expressed is gradually decreased, milk supply gradually decreases. Other suggestions for ceasing lactation include (Mohrbacher & Stock 2003, p. 198):

• Taking a shower or bath to aid with milk expression: Some mothers find that the warm water of a shower or bath helps with subsequent milk expression by relaxing the mother and stimulating a let-down
• Expressing milk as needed day and night: A mother may need to express her milk several times during the day as well as at night, depending on her child's former pattern of nursing.
• Using nursing pads: If a mother experiences leaking during the cessation of lactation, she can use nursing pads to absorb the milk.
• Using ice packs: If a mother experiences swelling, the application of ice packs to her breasts may provide some relief.
• Providing gentle support to the breasts: Binding the breasts has not been shown to be helpful when ceasing lactation. In fact, it may increase discomfort and result in plugged ducts or mastitis. A firm bra one size larger than usual may help provide gentle support.
• Restricting salt intake if a feeling of fullness occurs: Mothers may find that restricting salt intake helps reduce feelings of fullness, because salt causes the body to retain fluids.
• Drinking to thirst: Restricting fluid intake will not help decrease fullness or swelling of the breasts.

Because milk supply is a function of milk demand, the techniques described above are sufficient in and of themselves to stop your breasts from lactating. However, it is true that the breastfeeding literature reports that some herbs, such as periwinkle, sage (Salvia officinalis), and sassafras, have been used for lowering milk supply and for weaning (Riordan & Auerbach 1999; Humphrey 1997, 1998). Herbs and herbal preparations can be potent and can produce side effects-just like over-the-counter or prescription drugs. Therefore, they should be used only after consultation with a healthcare professional knowledgeable in their use.

According to Humphrey (1998), "Sage (Salvia officinalis) is noted in lactation and herbal texts alike as having a folk reputation for lowering milk supply (Bissett 1994, Riordan and Auerbach 1993). Peppermint (Mentha piperita) and parsley (Petroselinum crispum) are viewed by some traditional herbalists to lower milk supply, especially if the oil is taken internally in therapeutic doses (Ody 1994). Keep in mind that consumed on occasion, in small amounts and as part of a reasonably varied diet, peppermint, parsley, sage and other culinary herbs currently have no documented negative effect on lactation." In another publication, Humphrey (1997) writes, "Practitioners working with breastfeeding women need to know that herbs such as sage, for example, may decrease milk supply, even though no lactation studies have been done to verify this. Despite an otherwise conservative stance on lactation, Newall et al.6 do not cite ethnobotanical information about using sage for weaning in their recommendations for lactation, although they describe sage's folkloric use as a treatment for galactorrhea in another section. Other texts likewise mention sage's reputation as a lactation suppressant, yet fail to highlight this information when considering use during lactation.2" And, just in case you were wondering, the "dry-up medication" bromocriptine (Parlodel) is no longer sanctioned for use in women stopping lactation because it increases the risk of stroke, seizure, and death; for that matter it is ineffective at reducing milk supply beyond the postpartum period (Mohrbacher & Stock 2003, p. 198).

Now to answer your question about how to wean your son gently in this short time frame.... The more gradual weaning is for a nursling, the easier the transition will be. Even when weaning is required within three to four weeks, breastfeeding can still be gradually replaced with other foods or drinks and with extra affection and attention (Bengson 1999; Bumgarner 2000; Mohrbacher & Stock 2003). Specific techniques that you might consider using include:

• Explain what is happening: Using language your son can understand, you can explain that you need to stop nursing and whether you intend it to be temporary or permanent. Since he is only two, his understanding of the situation will be limited. However, because you know him best, you are the best person to figure out what kind of information might help him best cope with weaning.
• Be proactive with substitutions and distractions: Breastfeeding is a multifaceted relationship that meets many of a child's needs, such as for nutrition, nurture, social interaction, development, etc. Substitutions and distractions that work well will meet one or more of these needs. For example, if your son's nursing pattern is predictable, you can be ready with a healthy snack or drink or an alternate activity. You can make sure your son's appetite has been satisfied before you begin your bedtime routine: a healthy snack or drink before bed will reduce the likelihood that your son will be very hungry when going to sleep (and during the middle of the night). If breastfeeding has been his primary opportunity to have significant skin-to-skin contact with you, you could consider making backrubs or other forms of massage a regular part of his day/night. If you have not already done so, you could try engaging in a comforting action of some kind while breastfeeding (e.g., patting or rubbing his back, humming a soothing melody) so that it becomes associated with the feelings of closeness, comfort, love, and security that your son experiences during breastfeeding. Those comforting actions can then be used when you are not breastfeeding to convey those same feelings.
• Enlist the help of others: If your partner or another family member is available, you could ask them to take a greater part in your son's care, offering healthy snacks or drinks, helping create a new bed time routine, or helping with night time comforting.
• Change routines: It wasn't clear to me whether your son is also nursing during the daytime. If he is, you can change your usual routine so that he is not reminded by circumstance to nurse as frequently. For example, if you have a "nursing chair" or other favorite nursing spot in your home, you could avoid sitting there. Or, if your son always likes to nurse in the mid-morning when you are at home, you could be sure you are out of the house somewhere with many distractions during that time. Some mothers have their partner help their child get settled to sleep when they are working toward night weaning. The partner can be the one to help with pajamas, teeth brushing, book reading, etc. and can lie down with the child while rubbing his back or singing a lullaby until the child falls asleep. However, some children in the process of night weaning will fall asleep sooner when their mother is the one to help them to get to sleep. Experimentation and asking your son which kind of routine he prefers most will help you find new ways for him to get to sleep without breastfeeding.
• Delay nursings: If your son has no particular nursing pattern, you can try delaying nursing whenever he does ask. During the delay, you can offer substitutions and distractions. Some mothers find that a clear definition of the delay helps: "We'll nurse after I finish washing the dishes." Or if the request to nurse comes in the middle of the night, you could try saying, "We'll nurse when it's light outside." or "I'll rub your back for five minutes and then we'll nurse if you still want to." With that last statement, your sleepy son might fall back asleep before the five minutes are over.
• Decrease the length of nursings: When you do nurse your son, you can try to gradually decrease how long those nursings last. Some mothers find that a clear limit on the time helps: "We'll nurse until I'm done singing the ABC song."
• Be as flexible as you can: If it seems harder for your son to give up the going-to-sleep nursing than a middle-of-the-night nursing, you could work on eliminating a middle-of-the-night nursing first. If delaying a nursing is harder for your son than shortening a nursing, you could work on shortening nursings first.
• Provide an alternate sucking outlet if needed: Dr. Katherine Dettwyler estimates that-if culture didn't tell us to do otherwise-the natural age of weaning would average between 2.5 and 7 years of age (Dettwyler 1995, p. 39). Sucking is one of a child's needs that breastfeeding meets. If a child is weaned before he is ready, he may need to find another outlet for sucking (Mohrbacher & Stock 2003, p. 202). If this turns out to be the case for your son, options include thumbsucking, the use of a bottle, and/or the use of a pacifier. If your son understands that he cannot latch on to your breast and your treatment for breast cancer does not preclude him from being physically close to your chest, you can consider redefining "nursing." For example, he could still lay his head on your breast while sucking his thumb or using a bottle or pacifier. If there is a time period in which his being physically close to your chest is not possible (e.g., due to pain, radioactivity, recovery from surgery), you could consider engaging in this new form of nursing as soon as you are able. In the meantime, your partner or another loving person could hold him while he sucked his thumb or used a bottle or pacifier.
• Validate your son's feelings: Depending on your son's degree of readiness to wean, the process may go smoothly or it may pose great challenges. If your son shows that he finds these changes upsetting, you can encourage him to talk about his feelings while assuring him of your continued love. He has every right to feel whatever he is feeling about these unexpected changes. He may need far more hugs, cuddles, and kisses than he did before. He may need to cry and talk about his feelings while you hold him and listen, echoing back whatever he is saying, "You really want to nurse right now." or "You feel sad that you can't nurse." or "It is very hard to nurse for such a short time." Etc. If he still wants very much to nurse, a positive weaning may require a lot of time, energy, and patience on your part. So...

Abrupt changes in the nursing relationship are difficult for mother and nursling. This is true for both permanent and temporary weaning. It is even truer in your context of treatment for breast cancer. Both you and your child need support, encouragement, and acceptance. I hope those around you are able to provide it well. And I hope that something here is helpful to you, your son, and your family during this difficult time. Remember that there is no one right way to handle this situation.

References
Bengson, D. How Weaning Happens. Schaumburg, IL: La Leche League International 1999.
Bumgarner, N. J. Mothering Your Nursing Toddler. Schaumburg, IL: La Leche League International 2000.
Cooper, D. and Butterfield, J. Pregnancy subsequent to mastectomy for cancer of the breast. Ann Surg 1970; 171:429-33.
Dettwyler, K. A time to wean: The hominid blueprint for the natural age of weaning in modern human populations. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter 1995.
Humphrey, S. and McKenna, D. Herbs and breastfeeding. Breastfeeding Abstracts 1997; 17(2). Online at: http://www.lalecheleague.org/ba/Nov97.html
Humphrey, S. Sage advice on herbs and breastfeeding. Leaven 1998; 34(3):43-47. Online at: http://www.lalecheleague.org/llleaderweb/LV/LVJunJul98p43.html
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.
Peters, M. and Meaken, J. The influence of pregnancy on carcinoma of the breast. Prog Clin Cancer 1965; 1:471.
Riordan, J. and Auerbach, K. Breastfeeding and Human Lactation. Boston, MA: Jones and Bartlett 1999.
Susman, V. and Katz, J. Weaning and depression: another postpartum complication. Amer J Psychiatry 1988; 145(4):498-501.

Research has demonstrated that some vaccines for the mother enhance the health of breastfeeding babies, including vaccination during pregnancy against pneumococci (the leading cause of severe bacterial disease of infants and children globally) and maternal vaccination during lactation against rotavirus diarrhea (Mohrbacher & Stock 2003, p. 608; Pickering, et al. 1995; Shahid, et al. 1995). Insel and colleagues (1994) cite three studies showing increases in antibody levels in human milk following maternal vaccination with cholera and poliovirus vaccine during lactation.

However, the Centers for Disease Control and Prevention (CDC) does not suggest maternal vaccination during lactation as a viable option for protecting breastfed infants from the flu. According to Christine Pearson, a spokeswoman for the CDC (personal communication, January 26, 2004), "Influenza vaccination does not affect the safety of mothers who are breastfeeding or the safety of their infants. It's safe to get vaccinated for influenza if you are breastfeeding. However, there is no evidence to suggest that maternal vaccination offers a baby protection against influenza through breastfeeding."

References
Insel, R. et al. Maternal immunization to prevent infectious diseases in the neonate or infant. Int J Technol Assess Health Care 1994; 10(1):143-153.
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003.
Pickering, L., et al. Effect of maternal rotavirus immunization on milk and serum antibody titers. J Infec Dis 1995; 172(3):723-28.
Riordan, J. and Auerbach, K. Breastfeeding and Human Lactation. Sudbury, MA: Jones and Bartlett 1999.
Shahid, N., et al. Serum, breast milk, and infant antibody after maternal immunisation with pneumococcal vaccine. Lancet 1995; 346(8985):1252:57.

I am the mother of a one-year-old girl and am still breastfeeding. However, I think that I may have discovered a lump in my breast and am considering going in for a mammogram. Do you recommend pumping and dumping the milk following the mammogram, how many times and for how long?

Finding a breast lump can be a frightening experience. It can be hard to tell if a lump needs medical evaluation or if it is just part of the normal breast lumpiness that comes with the increased blood and lymph in the breast during lactation, as well as with the presence of more glandular tissue and milk. Lumps that do not decrease in size after nursing or that get larger over time certainly need to be checked by a physician. Other lumps may also need a physician's attention, for example, any prominent lump or a lump that coincides with fever and redness in the breast. Fortunately, lumps in the lactating breast are rarely malignant: only about 1 to 3 percent of masses that are diagnosed during pregnancy and lactation are due to cancer (Mohrbacher & Stock 2003; Smith & Heads 2002, p. 193). In most cases, lumps are milk-filled glands or are due to inflammation (e.g., a breast infection, plugged duct). A physician familiar with the lactating breast and experienced with breastfeeding mothers can check your lump and suggest a course of action. If your own physician does not have this familiarity and experience, you can request a referral to one who does.

Mammography is one of several diagnostic techniques that can yield information on the nature of a breast lump. During lactation, a mammogram can be useful in determining the size and location of a known lump (Mohrbacher & Stock 2003). In mammography, the breast is exposed to very low levels of x-ray radiation. Because human milk is not affected by a diagnostic x-ray, breastfeeding is not contraindicated after a mammogram. Breastfeeding may safely be resumed immediately after the mammogram is done (Mohrbacher & Stock 2003).

If mammography is recommended, finding a radiologist who has experience reading mammograms of lactating breasts is important because mammograms are more difficult to read during lactation (Mohrbacher & Stock 2003). This greater difficulty occurs because the tissue of the lactating breast is denser than that of the non-lactating breast-both because of the tissue changes that breasts undergo during lactation and because of the usual age of lactating breasts. Younger breasts are denser-and lactating breasts are often younger than the non-lactating breasts that more commonly undergo mammography. Also, lactating breasts have more tissue than non-lactating breasts. A mammogram may be easier to read if a breastfeeding mother nurses (or expresses milk from the breast) immediately before the mammogram because doing so minimizes the amount of milk in the breast. Because of the difficulty inherent in interpreting a mammogram of the lactating breast, mammography is often inconclusive and may not be the preferred diagnostic procedure (Riordan & Auerbach 1999, p. 496; Smith & Heads 2002, p. 192).

Other diagnostic tests that may be useful in evaluating a lump in a lactating breast include ultrasound, computer axial tomography (a CAT scan), magnetic resonance imaging (an MRI), and fine needle aspiration cytologic study (Mohrbacher & Stock 2003, p. 508; Smith & Heads 2002). As with mammography, breastfeeding can be immediately resumed after the diagnostic tests listed here (Mohrbacher & Stock, p. 508). Physicians and mothers with questions about the use of radiopaque or radiocontrast agents used with magnetic resonance imaging of the lactating breast can consult Dr. Thomas Hale's book "Medications in Mothers' Milk." Dr. Hale's book is updated every year and references the most up-to-date research available on many medications. Your local breastfeeding clinic, International Board Certified Lactation Consultant or La Leche League Leader may own a copy.

I hope that this information helps you make a more informed decision about your options for evaluating a breast lump. If you need more information about the interaction of medical procedures and breastfeeding, your local International Board Certified Lactation Consultant and La Leche League Leader can help you access it. And, if you are feeling anxious, I hope that you are able to talk about your concerns with someone you trust. Best wishes to you.

References
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book. Schaumburg, IL: La Leche League International 2003, pp. 508, 531, 608-609.

Riordan, J. and Auerbach, K. Breastfeeding and Human Lactation. Boston, MA: Jones and Bartlett 1999.

Smith, A. and Heads, J. Breast pathology. In M. Walker (Ed.) Core Curriculum for Lactation Consultant Practice. Sudbury, MA: Jones and Bartlett 2002.

I was unable to nurse our son as I had no breastmilk. I know this condition is extremely rare; I've heard my Grandmother had the same condition. I'd like to know what name of this condition is and might there have been anything that could have been done to facilitate the nursing experience for me? I'll always regret not being able to nurse my son, even though he's now ten years old.

Primary milk insufficiency or primary insufficient milk supply are terms for the physiological inability to produce a full milk supply. Hoover (2002, p. 219) estimates that probably no more than 1 to 2 percent of women are physiologically unable to lactate. It makes sense that primary milk insufficiency is rare, because if it occurred frequently the human species would not have survived. Insufficient development of the milk-producing glands and ducts of the breast is one possible cause; even with appropriate stimulation, the glandular tissue cannot produce enough milk (Mohrbacher & Stock 2003, p. 164). Powers (1999) estimates that this potential cause of primary milk insufficiency occurs in approximately 1 out of 1000 mothers-that's one tenth of one percent of mothers. Other causes include but are not limited to breast surgery, cancer, radiation, injury, trauma, and congenital disorders that damage breast and nerve tissue, negatively affecting milk supply (Mohrbacher & Stock 2003, p. 164; Riordan & Auerbach, pp. 314-315). Severe postpartum hemorrhage resulting in Sheehan's syndrome can also result in low or absent milk supply (Riordan & Auerbach 1999, p. 314-315).

When a mother does not produce enough milk, it does not necessarily mean that she cannot produce enough milk. Secondary milk insufficiency or secondary insufficient milk supply are terms for not producing a full milk supply when the production of a full milk supply is physiologically possible. Possible causes include but are not limited to:

• the mismanagement of breastfeeding (e.g., infrequent and/or short feedings, supplemental feeds of water or formula that cause the breasts to make less milk, not feeding the nursling at night)
• interruption of breastfeeding for medical or non-medical reasons without protecting the milk supply by pumping or hand expression
• maternal eating disorders
• insufficient emptying of the breasts because of health or behavioral issues in the nursling (e.g., oral defensiveness from suctioning, physical discomfort from birth trauma, feeding confusion from the use of artificial nipples, feeding difficulties due to a congenital disorder, prematurity, sucking problems from the effects of labor medication) without protecting milk supply via pumping or hand expression
• treatable maternal health issues (e.g., retained placenta, anemia, low thyroid hormone, other hormonal imbalances [e.g., polycystic ovary syndrome]).
• maternal smoking, consumption of alcohol, the use of some oral contraceptives, some herbal preparations or seasonings (e.g., mint, sage), and some medications (Hoover 2002, pp. 219-223; Mohrbacher & Stock 2003, pp. 160-166).