I had a doula client once who was struggling to breastfeed her baby. Nikki's baby was on her breast about 50 minutes of every hour, 24 hours a day. We were in contact daily, either by phone or in person. I kept connecting her with IBCLCs to troubleshoot the issue.
 
The first IBCLC was Ashley. She was very experienced, and a friend of mine. She suggested Nikki pump after each feeding and then offer the baby breastmilk in a bottle – in addition to feeding him at the breast. Nikki tried this and quickly realized it may help her make more milk, but it was not helping her stay sane. Ashley had to go out of town, so she suggested we meet with another IBCLC, Brenda.
 
Brenda was a very new IBCLC, having just passed the exam -- and she was also a friend of mine. Without regard to Nikki, Brenda created a plan to have mom weigh baby before and after every feed and record this information on a sheet of paper that looked like a chart with about a hundred boxes on it (read that sentence a few times so you feel overwhelmed -- that was the intent). Nikki didn’t even get so far as to try this – she said, sadly, “I can’t imagine being able to do all this without having a full-time nanny.”
 
Alone, Brenda and I discussed the situation. “What do you think?” I asked.

“I don’t really think there’s an issue – I think it’s in her head.”
 
I was hurt by this statement! I had wiped this mother’s tears, sat with her and listened to her share her fears that she was starving her baby -- that she just knew something was wrong. I didn’t realize how damaging it is to hear a care provider state she doesn’t believe her client/patient.
 
Compelled to say something, I responded quietly: “Whether it is real or not, it is real to her. How can you help someone if you don’t believe them?” This was real bravery on my part, to tell Brenda how I felt. Embarrassed and feeling vulnerable, I changed the subject. In a couple of minutes, I made up an excuse to leave.
 
I didn’t say anything to Nikki about this exchange, but she chose to discontinue seeing Brenda. Working hard to keep breastfeeding, she continued to nurse her baby as often as he needed, leaving time for just about nothing else. Exhausted is not even a word to use here – Nikki barely had time to use the bathroom, eat, or shower – forget about self-care, healing, meaningful time with her partner, or just stopping for a minute. Everything was rushed, and what was accomplished was accomplished with a baby crying in the background.
 
I was able to finagle one more meeting with a third IBCLC, Carly. She was very experienced, and also a friend of mine. Normally Carly wouldn't have been an option because of insurance issues, but as I discussed the situation with her, she agreed to see Nikki.
 
I was so excited to share the news with Nikki! I called her immediately and said, “Guess what? Carly can see you! She said to just call and set something up!”
 
Then came a long pause, and, “You know Stacie, I think I may be done.”
 
Oh, my heart fell. I knew how hard she was working. I knew for Nikki these early days were not about bonding and enjoying her new baby, but about feeling scared and always feeding, all-around-the-clock. I wouldn’t fault her for moving on and putting the breast to rest. Who could? And knowing what I did about this woman -- as we had been building a relationship for months -- and witnessing the strength and power she built and held during her birth, I was concerned she might look back and regret not having tried just one more thing.
 
I didn’t want to press her, and I resigned myself to one last sentence on the matter before leaving it all alone: “I would hate for you to look back and wonder if this might have helped.”
 
And then I changed the subject.
 
After we had been talking for about 10 minutes, Nikki interrupted the conversation with – “Okay, I’ll see her.”
 
This mother had PCOS, which we all knew, but as her milk came in promptly after birth, we mostly put that on the back burner. Baby was gaining 4ish ounces a week, nothing terrible enough to raise a red flag with the pediatrician. And like I previously mentioned, her baby was on the breast almost constantly.
 
At this consult, Carly suggested Nikki ask her doctor for a Domperidone prescription, to increase her milk supply. Carly felt Nikki could stop pumping (more like, stop feeling guilty about not pumping). Carly suggested if the baby was nursing that often, there should be adequate stimulation to keep up Nikki's supply. Nikki finally felt her needs were being taken into account as this plan was created and shaped -- that meant it was more likely to be followed. 

And things got better, quickly. Nikki got the medication on a Wednesday. She and her husband and baby were going out of town for a weekend wedding. She called me, overjoyed on Saturday, saying she was already making more milk, and her baby was happy and satisfied. “He has been eating every couple of hours instead of every hour for 50 minutes! For the first time ever!”
 
So what’s the point here?
1. I knew all of these IBCLCs well and continued to trust and refer moms to them. It wasn’t that any one was better than the other. No one made a mistake or mishandled the situation. It’s just that something different came into each lactation consultant’s mind first, and that is part of being human.
 
2. When we are in a helping position and a mother tells us the plan we have created isn’t going to work, we need to let go of our egos and the feeling of wanting to discount the mother and her experience. She has a better picture of what is happening in her life than anyone else, and we need to trust that.
 
3. If you are presented with a plan that doesn’t seem workable to you, that doesn't mean you are stuck. A care plan should be made with you in mind, not absent of your specific needs and unique challenges. Seek out a second opinion. Even a third. Because you never know  -- sometimes the third time’s the charm. 

Just a few end notes:

• All names have been changed.
• This happened 10+ years ago, when Domperidone was easily available through compounding pharmacies.
• Just as Carly "saved the day" here, I know for a fact Ashley and Brenda have had instrumental roles in stories just like this.
• PCOS is a very complicated issue, and women aren't always aware it might affect breastfeeding. In my opinion, one of the best sources of information about PCOS and breastfeeding for moms is "The Breastfeeding Mother's Guide to Making More Milk," by Diana West and Lisa Marasco.

One of the jobs of a doula is to provide resources to pregnant women and their families. We may provide a list on a piece of paper, or provide verbal information regarding different resources in the community. It could be anything from where to find a childbirth educator, a lactation consultant, an IBCLC, or even where to locate other new moms. Often an area that is forgotten or which is not known is information regarding milk sharing. What is milk sharing and how can doulas offer this as a resource to new mothers?

On page 10, paragraph 18, in the “Global Strategy for Infant and Young Child Feeding” by The World Health Organization (WHO) and Unicef (2003), it states the hierarchy for infant feeding. If a child cannot be fed directly from the mother’s breast, first the child should be fed the mother’s expressed milk, secondly the child can be fed donor milk through a wet nurse or milk bank, and then finally a breast milk substitute can be fed (WHO & UNICEF, 2003). There is caution to be taken when feeding a breast milk substitute, though. WHO and UNICEF (2003) state, “Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.” In this hierarchy of infant feeding options, donor milk is often neglected, but should be considered before a breast milk substitute is given.

Milk sharing is a centuries old tradition. Centuries past there was a process called wet nursing which utilized the services of a mother, with or without her baby, to feed another woman’s baby (Thorley, 2008). Sometimes this was done forcibly by slave owners, and other times there was compensation given to the lower class women who provided this service to those in the upper class (Thorley, 2008). In modern times, wet nursing is sometimes confused with cross-nursing which is the feeding of another woman’s baby out of a sincere desire to help without compensation. With time, these traditions began to fade away, and soon it was close to non-existent (Thorley, 2008). Oh, that’s not to say it wasn’t happening! It just wasn’t widely practiced anymore, because it was much harder to find someone who could cross nurse a baby. However, in the last four and half years, there has been an increased awareness of the benefits of peer-to-peer milk sharing also known as: informal milk sharing.

Currently, informal milk sharing is the process of donating excess, expressed breast milk to another baby in need of breastmilk without going through a milk bank. A mom who is producing enough milk for her baby, may choose to pump additional milk over and above what her baby needs in order to donate this excess milk to another baby. Many woman have chosen to save their milk to donate it to a baby whose mother is not able to produce enough for their own baby. A breastfeeding mom will generously donate her milk in an altruistic fashion. There is no monetary compensation during this milk DONATION. The compensation is knowing that her milk is feeding another baby in need.

There are many reasons why a baby would need donor milk. The baby’s mother may have health issues like cancer, insufficient glandular tissue, may be on medication that is not compatible with breastfeeding, or a host of other health issues too long to name, here. The baby may have been adopted, and the new parents want to provide their baby with the biological normal sustenance, breast milk. The mother’s milk may have taken a dip, and she is no longer producing enough to fulfill the baby’s nutritional needs. The mother may be returning to work or school, and does not have enough of a supply stored away. The baby’s mother may have passed away, and the family seeks out donor milk to continue feeding the baby breast milk. This blog post could be pages long with the myriad of reasons why families seek out donor milk. The simple and hard fact is that there are babies who need donor milk to meet their dietary needs in a manner that is consistent and compositionally the same as their own mother’s milk.

The growth and accessibility of social media has facilitated the exponential increase in the availability of donor milk. In Oct. 2010, in a grassroots efforts which opened up the doors to thousands of babies in need donor milk, Facebook was utilized as a platform to create Human Milk 4 Human Babies (HM4HB). This was the beginning of reaching scores of moms who had an excess amount of breast milk. Donor families used HM4HB to find recipient families who had a need of donor milk and vice versa. Years ago, it would have been difficult, if not impossible, to find someone locally who was breastfeeding and could provide a baby with donor milk. However, using social media, there is now a much faster method of reaching out to people in the community when there is a need. Informal milk sharing, although it had been happening on a much smaller scale, exploded. Volunteers generously committed hours to the creation of HM4HB public Facebook pages. These pages were set up all over the world to facilitate a place where families could search for other families willing to donate their breast milk. 

The process of informal milk sharing is completely dictated and handled by the families who are donating or receiving breast milk. While there are risks involved both in breast milk substitutes and informal milk sharing (Gribble & Hausman, 2012), families must weigh these risks, ask any questions, including health questions or concerns, and make an informed choice. Informal milk sharing on HM4HB is the sole responsibility of each of the individual families. Administrators of the pages do not get involved in any manner other than to post requests/offers, or delete off topic information. Because of this, HM4HB does not have statistics showing how many people on their sites are sharing their milk and receiving donor milk. HM4HB operates much like a bulletin board. People post offers/needs, admins keep the place tidy.

What about milk banks, you might ask? A non-profit milk bank, like the Human Milk Banking Association of North America (HMBANA) receives donor milk from families who have excess breast milk. This milk is reserved for the most vulnerable from our communities, preemies and ill babies. So, a healthy six-month old whose mother has had a decrease in milk production, would not be eligible for milk from a milk bank. While we NEED milk banks to provide milk to an extremely needy population, they cannot provide milk to all the babies. Additionally, there are restrictions for who can donate breastmilk. For example, a mother on herbal remedies would not be eligible to donate. Milk bank donor milk is being served to extremely delicate babies who have fragile immune systems and their donor milk must meet the strictest of standards. Hence, informal milk sharing is a valuable resource for families who don’t meet milk bank requirements for donor or recipient.

As doulas, we can offer much in the way of support to families. An additional way to offer that support is to provide information to clients regarding informal milk sharing. We can share HM4HB with families. We can let them know that informal milk sharing is an option available to them. Now, with this blog post, you will be able to direct them, here, so your clients can read for themselves what informal milk sharing entails. Or you can send them directly to HM4HB.

Had you heard of informal milk sharing before this reading this post? Have you been a donor or recipient? What are your experiences? Will you share this information with your clients? 

Gribble, K. D., & Hausman, B. L. (2012). Milk sharing and formula feeding: Infant feeding risks in comparative persective. The Australasian Medical Journal, 5(5), 275-283. doi:10.4066/AMJ.2012.1222

Thorley, V. (2008). Sharing breastmilk: Wet nursing, cross-feeding and milk donations. Breastfeeding Review: Journal of the Australian Breastfeeding Association, 16(1), 25-29.

WHO & UNICEF. (2003). Global Strategy for Infant and Young Child Feeding.

Today marks 33 years of the WHO code, or the International Code of Marketing of Breastmilk Substitutes. Social media outlets of all kinds are trying to inundate businesses today who choose not to comply with this code -- add your picture to show your support.

 In my post about getting a breastpump, I mentioned the WHO-Code and different companies who are or are not in compliance with the code. But what is the Code? And who cares? Or should I say, WHO cares? Here is a break-down:

Everything that was decided was done so in order to protect breastfeeding and breastmilk. We know not everyone can breastfeed, and not everyone chooses to breastfeed. Formula isn't the subject up for debate -- it is a necessity in our world and it is the safest option we have for babies not receiving breastmilk. But the way formula companies advertise undermines breastfeeding.

For example, have you noticed advertising often depicts breastfeeding moms as lounging in their beds and their pajamas all day? Or surrounded by expensive-looking gourmet or "extra-healthy" food? The message is simple: To choose to breastfeed, you will be tied down to you home, your bed, your pajamas, and you baby -- and you must eat costly food to be healthy enough to nurse.

Moms depicted giving their babies bottles of formula, on the other hand, look put together, dressed professionally, ready to take on the world with their awake, alert babies. Or better yet, just a cute baby alone with her bottle, showing independence!

Celebrate the making of the WHO Code, and the businesses who choose to comply with it. When breastmilk is not the option, we know formula is available. Unethical marketing practices only serve to hurt moms and babies. 

Through the ACA, insurance companies are required to cover a breastpump for women who have nursing babies.  I am not going to get all law-tech-bureaucratic on you, but since I recently went through the process and have had a lot of inquiries on how it worked for me, I thought I would share my experience.

It is my understanding that even though this is something insurance companies are "required" to offer, the follow-through is what varies from company to company.  Some only allow a manual breastpump; some allow a higher-quality, hospital-grade pump if your baby was premature.  Still others set the fee of what they will cover, and if you go over that with upgrades or a higher-level pump, the difference is yours to pay.

After Ezra was born in April and we were dealing with his tongue and lip ties (which I wasn't aware of yet), I called my insurance company (Anthem Blue Cross) to see about getting a pump.  They gave me the information for two DMEs (durable medical equipment suppliers).  I was in a lot of pain and experiencing a lot of engorgement.  I was desperate!  I called one company, and even their hold message stated they were backed-up for pump orders.  I hung up and called the other DME.  After some waiting, I got through.  They only offered two pumps: Playtex and Medela.  Coming from a breastfeeding advocacy background, this wasn't good to hear.  My issue with Playtex:  We often counsel women not to buy pumps from companies that make bottles -- the research and science isn't there when it comes to putting together a breastpump that works well.  My issue with Medela:  They are no longer WHO-code compliant (easy to understand info here), and while that isn't the biggest deal to some, it is something very important to me. After a lengthy conversation, exchange of a lot of information, and a hot cell phone to my head (hot baby to my chest, hot engorged breasts), I chose the Medela pump.

I waited a week, and after not hearing from anybody, I called the DME to see what the status was.  I was told I needed to pay around $80.  Now I had been told by my insurance company I would pay 20%, so $80 for a $250ish pump seemed wrong to me.  I talked to someone else in some other department, and she said they would look into it and get back to me.  What really must have happened was, the order got cancelled, because I never got a breastpump, and they never got back to me.  But by then, I was feeling much better and we had worked some of our issues out.

Fast forward to about a month ago.  I was at a LLL meeting and a mother said she had just ordered a Hygeia pump through her insurance and they covered the whole thing at 100%.  I then learned, we had the same insurance!  This was her advice:  Contact Hygeia directly and tell them you want their pump.  I did, and a week later, I got my pump, nothing paid out of pocket, and I already have some milk in the freezer!

Not everyone's process will be that easy.  It is worth a try, though. My understanding is, you have from your third trimester until your baby's first birthday to get a pump.  I didn't think about getting one before birth because I have been trained and ingrained to counsel women NOT to buy pumps while pregnant.  It is often on that baby registry -- a Medela Pump in Style (PIS).  With my childbirth ed classes I have suggested, if a woman isn't going back to work or school immediately, to hold off on buying a pump. With more time and a meeting with an IBCLC, often a women can better determine what type of pump will fit her needs best, versus the PIS simply because that is the one she has heard of, and her sister/best friend/next door neighbor used it, and maybe even someone is giving her their old pump, so she's set.

The thing about the PIS is, it is not the best pump out there -- like we say about carseats, the best carseat for your child is the one that best fits your child AND your car.  Same with pumps.  The best pump is the one that best fits you, not only physically (nipple size) but also functionally (are you going back to work or will you just need some milk for date night?).  Pumps are pricey...they aren't always something needed before a baby is born. In the beginning, mom and baby are supposed to be determining how the relationship goes, how to latch, how often to feed, how much milk, etc.  The pump, under normal circumstances, doesn't need to be a part of that early relationship.  If a woman finds herself pumping, it is often because there are some adjustments needed due to soreness or pain, and that is where a LLL Leader or IBCLC can come in handy.  If you have a premature baby, or a baby who is unable to latch, of course a pump is what you need to protect the milk supply until baby can return to the breast, so don't think I am saying it always goes smoothly -- I know it doesn't.  In situations like that, though, a hospital-grade pump, which needs to be rented, is almost always going to be a better choice, so you still wouldn't miss out if you hadn't purchased a pump before birth.

Back to the giving-away-of-the-old pump:  I admit, I used my sister-in-law's pump 14 years ago, when my baby was in the NICU for two weeks, and I was grateful to have it.  I knew nothing about pumps, barely anything about breastfeeding.  At that point it had been used for three of her babies, and I am sure it had logged many, many hours.  I don't worry that I could have cross-contaminated my milk in there (the PIS is an open-system, which means milk could potentially get into the motor and come in contact with the next mom's milk), but I probably should have worried about the potential for mold growth and my sick NICU baby's health, or even bugs that can get into the motor(yes, cockroaches can visit and maybe even stay).  Pumps are so expensive, though, it isn't unusual for us to want to share them when we are done, or to even sell them to strangers.  Please, don't.  Not if your pump is designed as a single-user item -- treat it like nose-hair trimmers -- you wouldn't share those with anyone, would you?

Hygeia knows when you spend so much on something and it still has life left, you are likely to share it -- and their closed-system allows this simply by having the next woman purchase her own pump parts -- the tubing, the flanges, the storage containers.  Ameda also makes a closed-system pump.  Bailey is another great quality, lesser-known company that makes pumps.  Like I said before, just because Medela is the best-known, doesn't mean they are the best for you.

Once you decide you want a pump, check out who your insurance company's DMEs are; if they have a pump you like, then go for it.  If you want more choices, try contacting the pump company directly to see what DME they suggest.  I just have to say:  The amount you can pump does not determine how much milk you have -- some women don't respond well to pumps, that is a fact.  If you need help pumping or breastfeeding, contact someone -- you don't have to figure this all out on your own.  LLL Leaders can answer questions and provide information about how to pump more successfully, and a personal consultation with an IBCLC can be invaluable when you are tying to figure out the hows and whys and whens of pumping when you are getting ready to go back to work -- they are a wealth of information.

I do not have any relationship with Hygeia, I am just super-impressed with the measures they take to make their pumps relevant in a market where $200 pumps could essentially be tossed in landfills if they were truly being used properly. 

I would love to hear about your experiences with obtaining a breastpump through the ACA.