Operation Grow Joey: Part 1

I used to say that I love breastfeeding because I’m lazy. Think about it… not having to get out of bed to prepare a bottle when your child wakes up hungry? Excellent. Running errands without packing milk or formula, because you have your breasts with you all the time? So convenient! Never washing bottles? Awesome.

Now I know better. I’m not lazy at all when it comes to feeding my babies.

Faced with difficulty, I’ve been working day and night to make sure my littlest still gets breast milk. I’ve basically become an exclusive pumper (EPer). Lots of people exclusively pump for their babies, for various reasons. It isn’t something that I personally would choose “on purpose”… given the choice between breastfeeding and pumping, my preference would clearly be breastfeeding. But when it’s a choice between pumping and formula? I’ll pump.

I’ll pump all day if I have to (and I have been). I’ll set alarms to wake up in the middle of the night and pump. I’ll give up my lazy morning snuggles if it means I’ll get 2.5 more ounces than if I stay in bed. I’m not lazy.

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Not Just Small

A friend of mine, who is a nurse and mother of 5, sent me a text earlier in the week, encouraging me to make sure everything was going okay with Joseph. She said, “I don’t think he’s just small.”

I was small. I was tiny. For years. So his overall size hadn’t concerned me. Some people are just small.

He is happy. He laughs. He is learning… grabbing toys, rolling over, peeing and pooping. His fingernails grow at an alarming rate. He usually takes 2 fairly reliable naps a day, doesn’t over sleep, is alert and engaged when he’s awake.

Still, I value my friend’s thoughts, and her level of experience with these issues made me take her a bit more seriously than, say, if someone had stopped me in Target to say, “dude, your baby looks too small.” And honestly, I wasn’t sure HOW small Joey was. So I weighed him on our scale at home. (Mom+baby – Mom = baby) Several different times over 2 days, my scale said that he was 12 pounds. I did the math… his lowest point after birth was 6.5 pounds. He just turned 4 months old, so that’s a 5.5 pound gain… which is just under the low end of normal range of gain for a breastfed baby.

Except that he wasn’t 12 pounds. I took him in to get weighed by the nurse at our pediatrician’s office, and with his clothes and diaper on, he weighed only 10 pounds 15 ounces. Way too small. Off the chart small. (Yes, the WHO chart, not the AAP chart). I nursed him, and we weighed him again. Only 11 pounds. 1 ounce of milk transfer. Not enough. Not by a long shot.

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I thought to myself that maybe he hadn’t nursed well at the hospital because I was sitting in an uncomfortable chair in an exam room, not able to fully relax. Anneliese was asking to go potty the whole time, so that was distracting for me and for Joseph. He kept looking around at the new room, and so forth.

So I planned to schedule a weigh-nurse-weigh session with an IBCLC at my house, for a home visit.

I also scheduled an appointment with the hospital lactation consultant to follow up in a week, and see how much weight I could help Joey gain in the meantime. She said that sounded great, and made sure I knew that if he didn’t gain well, his pediatrician would want to refer him out for a Failure To Thrive work-up, which would include blood work to rule out various metabolic issues, and maybe GI testing to make sure his “mechanics” were working properly.

My friend had told me that some babies don’t give any other sign of something being wrong… other than simply being too small. The term for this is, “Content to Starve.” Can you imagine? Being hungry all the time, but just not really caring because it’s all you know? I’m in tears thinking about my poor baby literally starving, but soldiering on with a smile every day. You’d think that if a baby wasn’t getting what they needed, they’d let you know. They would cry, wail, scream, until you got help for them. Either that, or they’d sleep all day long to conserve energy. But that isn’t always true.

A content to starve baby will eat just enough to not be hungry anymore, then stop. And that’s not enough.

Good Supply

I knew it wasn’t an issue of milk supply. I’ve felt since Joseph was born that my supply is better than ever. My let-down seems faster than it ever was when Anneliese was young, for the first time I could manually cause milk to squirt “on demand,” and often when tandem nursing, I would hear both baby and toddler gulping happy gulps…for a long time.

So what then?

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Observation

I paid close attention to Joseph’s nursing for the next day. I guess when you have a toddler to chase too, you don’t necessarily give nursing your full attention. I noticed that he wasn’t swallowing as much as I had thought he was. But when I nursed him WITH Anneliese (when I was used to paying attention, because I wasn’t chasing Anneliese), he nursed much better. Swallowing more.

Another friend was visiting that day, and her presence made me that much more aware of just how much Joseph spits up. His copious amounts of spit-up was something I had brought up at several La Leche League meetings, and asked other moms about. The general consensus was that if it didn’t bother him, it wasn’t really an issue…beyond needing to have burp cloths everywhere.

But it’s an issue if the baby is spitting up nearly everything he’s taking in, even if he is giggling while doing it.

So I had two immediate goals:

1. Get more milk into Joey.
2. Get more milk to STAY in Joey.

Research

I can’t really recall the specific order of the things I was reading… because my research was near-frantic… googling causes of excessive spitting up, homeopathic remedies for spitting-up/reflux, reasons for poor milk transfer despite good supply, and thumbing through The Breastfeeding Mother’s Guide to Making More Milk for something I might have overlooked. All at the same time.

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And I found it. Suddenly everything converged, and everything made sense. I felt so relieved, because it meant I could formulate a plan to help Joseph.

Posterior Tongue-Tie

Tongue-tie, or ankyloglossia, means that the tongue is anchored to the floor of the mouth by the lingual (tongue) frenulum (or frenum). This means its mobility is hindered, and the baby’s ability to lift the nipple, cup it to squeeze out milk, and create a vacuum at the back of the mouth to suck and swallow the milk is compromised.

Full tongue-tie or anterior tongue-tie is much more noticeable and easier to identify than posterior. But any kind of tie can cause huge problems. From Making More Milk:

p. 89 Any type of tight frenulum can lead to feeding fatigue, poor milk transfer, slow weight gain, and ultimately, low milk production if the baby cannot remove milk effectively from the breast.

p.90 Inadequate feedings are common as baby wears out from his efforts before his tummy is full, and tongue tremors may be visible as he tires. He may fall asleep quickly and awaken hungrily a little later, or feedings may feel more like marathons as he slowly keeps working to fill his belly.

I’ve seen the tongue tremors, but since they’re similar to the quick fluttery sucks at the beginning of nursing, I assumed he was working to get a second let-down when that happened. I didn’t know he was exhausted by nursing, and wearing himself out. His best naps often happened after tandem nursing with his sister, which makes so much sense (I’ll explain in a bit).

Another excerpt from Making More Milk helped me confirm the theory that would explain everything.

p.92 Dr. James Murphy suggests pushing your little finger to the base of the tongue on one side and sweeping it across to the other side to see what you can feel… When you can’t sweep your finger across without pulling it back to “jump over a fence” the frenulum is a fibrous band attached closer to the front of the tongue… “Tree trunk, “ “fence”,” and “piano wire” frenulums are red flags for significant tongue function impairment.

Crazy… I thought everyone’s tongue had a “fence” under it. Mine does. So I guess I also have posterior tongue tie. It never caused any issues for me – I was bottle-fed formula as a baby, and had no problems eating food or speaking later on. I asked my husband if I could feel under his tongue, and sure enough, he has a normal “fenceless” tongue. Totally smooth. I felt my own frenulum again, then Joey’s, then asked Anneliese if I could feel under her tongue. As much as I could feel before she bit me (ha!), hers felt more like my husband’s.

But apparently posterior tongue-tie is something that can run in families. Who knew?

Thankfully, a frenotomy is a simple procedure to divide the membrane in order to free the tongue. It is usually preformed without anesthesia as there are few nerve endings (or blood vessels) in the frenulum. It can either be cut with blunt-tipped scissors or a laser, and sometimes a bit of gauze is applied to absorb any spotting of blood, after which the baby is allowed to nurse. Mothers often notice a huge and immediate change in latch and nursing behaviors after the procedure is completed.

Unfortunately, in older babies, the incorrect nursing technique will have to be un-learned, and proper latch and sucking will need to be taught. Babies can figure it out through trial and error, but there are exercises you can do with your baby to help the process and strengthen the formerly-unused portions of the tongue.

The Cause of Reflux

With the knowledge that Joseph is tongue-tied, I concluded that his spitting up has most likely been caused by inefficient latch and sucking, and uncoordinated swallowing, which would lead him to swallow more air than he should as he nurses.

This has basically been confirmed over the last few days, as he barely spits up when being fed from a bottle. Except for when I accidentally gave him too much milk at once and over-filled his little tummy… LOTS of spit-up then. Today I’ve made a point of giving him smaller bottles more often, and he has only dribbled a little while playing on his tummy. Like a normal baby.

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Tandem Nursing

Anneliese has been nursing throughout Joseph’s life, and now I realize she has probably done 2 major things for Joseph.

1. Helped him to get more milk. When they nurse at the same time, Anneliese (the “professional”) is able to get both breasts to let-down, and Joseph has a much easier time of nursing because the milk is already flowing. He swallows more and sleeps better afterward.
2. Protected my milk supply. Were it not for Anneliese nursing, I think I would have had a significant supply problem by now due to insufficient milk removal. The way I had been tandem nursing – nursing Joseph first, then letting Anneliese nurse on the side he just “finished” while he switched to the opposite side (where he had an easier time because Anneliese helped with let-down) – was probably the best case scenario for the situation. Other than, of course, earlier detection of the problem.

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Don’t Look Back

So many things have been running through my mind these last days, this last week. Clues I should have noticed, questions about Anneliese’s size as a baby (though she wasn’t nearly as small as Joseph is), things I should have done or checked or asked about… but I can’t do that. It’s unproductive and unhelpful. And wracking myself with guilt won’t solve anything. It’s pointless.

So I’m moving forward. (And please don’t ask me about “clues” or “signs” or anything else… because I’m really moving forward. Feel free to ask me anything about the current situation.)

I’m doing everything I can to make things right for my tiny boy.

And I know everything is going to be okay.

“I did then what I knew how to do. Now that I know better, I do better.

- Maya Angelou

Becoming an EPer (Exclusive Pumper)

My first impulse was to pump and use an SNS (supplemental nursing system) which is a bottle that hangs around mother’s neck on a lanyard, with a tiny tube taped to the nipple, so that when baby latches onto the breast, he can suck mother’s milk “from the tap” and from the bottle simultaneously. This keeps the baby nursing and also stimulates the breasts to produce more milk.

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After my first half-day of pumping, however, I gave up on that idea for the time being. I realized that my breasts were going to get PLENTY of stimulation, and that Joseph, without his frenulum divided, wouldn’t be able to latch properly anyway. It would probably be more frustration than necessary for all of us.

My days have gone something like this, since Saturday:

1. Give Joey a bottle with a few ounces of breast milk in it.
2. Change his diaper.
3. Set up my pump and strap on my hands-free pumping bra.
4. Pump for about 20 minutes. (occasionally I pump while I give him the bottle)
5. Measure milk into a bottle, record, and put pump parts in the fridge.
6. Nurse Joey and/or Anneliese.
7. Do a couple of small things. (Help Anneliese potty, get something to eat/drink,
8. Repeat about 10 times.

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My breasts are BUSY. I don’t need to add an SNS into the mix right now, and like I said, it probably wouldn’t be the best for Joey right now either.

This is how much time I’ve been spending each day just to feed Joseph – nursing, pumping, and bottle-feeding. Less nursing lately because he has started to bite me (explained in a bit). This screenshot was obviously taken just after 4pm, but the evening will be full of the same. Longer pumping sessions are “power pumping” sessions designed to mimic cluster feeding and increase supply. I’m doing 20 minutes on, 10 minutes off, 10 minutes on, 10 minutes off, 10 minutes on, but there are lots of different versions of “power pumping.”

I’m also still nursing Anneliese a few times a day, usually after pumping if I can arrange it that way… and that is not recorded on this chart.

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EPing is so different than pumping for work… someone who is pumping because they’re going to be away for several hours can “catch up” to their baby by pumping extra on weekends, or adding a morning session before leaving for work work, or reverse cycle, nursing more often when they’re home so their baby needs less while they’re away. When you’re pumping for 24/7, there’s no “extra” time.

Pumping is always going to be less efficient than nursing… well, unless your baby is tongue-tied or has another palate/facial/lip/tongue  deformity that compromises his ability to nurse well. So I’m struggling to keep up right now.

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I’m taking a lot of More Milk Plus throughout the day, and my pumping output has gone up a little bit already (it only came in the mail Monday, even though I ordered it with expedited shipping so it should have arrived on Friday, so I haven’t been taking it for long). Also, I smell like maple syrup.

And the same friend who encouraged me to investigate Joey’s small size is so generously pumping and sharing her milk with us. I have been keeping up with Joey pretty well throughout the morning, but in late afternoon, my supply dips (which is common, whether nursing or pumping), and I have to thaw some of hers. I’m so lucky to have such a great friend helping me to continue feeding Joseph human milk.

No Longer Content

I’m trying to keep Joey nursing as much as possible, so he doesn’t forget how… well, as much as he knows how.

But since he has been feasting for almost a week now, he is no longer “content to starve.” He gets impatient at the breast because there isn’t immediate flow (especially as I’m trying to nurse AFTER pumping), and he bites now. Biting or chomping/clenching down with the gums is a sign of tongue tie, because since the tongue can’t effectively compress the nipple, babies will try using their gums to squeeze milk out. “Content” babies don’t do this, so he never bit me before.

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This is really, really hard for me. I’m in tears just writing about it. I love the soft sweet cuddles that breastfeeding brings, and I love the long nursing relationship I have with Anneliese. I want that with Joey. But right now, it’s on pause.

He nurses much better when he is very sleepy (and full), I guess because there’s nothing else he’d rather be doing. The world beyond Mama’s breasts is too exciting for him when he’s sleepy. Cuddles are good. So I’m cherishing those moments of good latch and snuggles.

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As He Should Be

Apparently the guy I thought was so “chill” and “laid back” from birth is a bit more exuberant than I thought.

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This is before… so focused and precise. I guess he was conserving energy and being “content,” not just being a serious kid. “Intense baby” is apparently one sign of tongue-tie. Here is my intense baby.

And I took this video today… MUCH more batting and playing happening. (Also, breast pump sound in the background. Of course.)

I had to put him in the boppy to play because he was rolling over so much too. He was rolling before, but like once… now he’s rolling and flipping and doing 360 degree turns pivoting around on the floor. This is the way he’s supposed to be. My chilled-out “intense baby” is becoming more playful and active. As he should be.

Frenotomy and Back to Breast

After a weekend of pumping and bottle feeding, and the absence of much spit-up, I took Joseph back to the hospital IBCLC to be weighed and to give her an update.

Since we had weighed him with clothes on before, we weighed him with his clothes on again to get a good comparison. The results were astounding. He had gained somewhere around 9 ounces in just under 3 days of this new protocol. (Then we weighed him naked, to get a good baseline for future weigh-ins.)

I told her about my tongue-tie discovery, and she checked his tongue and confirmed his tie, then told me I was right that it could explain everything. She called Joseph’s pediatrician in to share the good news of his weight gain.

He told me that his significant gain probably ruled out any metabolic cause for his “failure to thrive” (I hate that term… how about “slow gaining”?) which would save him a lot of poking and prodding. Then he told me he could put in a referral to another doctor to have his frenulum clipped. He named a few doctors, and I asked for a referral to one my IBCLC/doula had mentioned before as being a good one.

Now we wait… the referral has to be approved and processed by our insurance company, which can take about a week. After that, we have to see where we can fit into the doctor’s schedule. I’m hoping it’s soon, something he can “squeeze in” since it’s such a quick procedure.

Once his frenulum is separated, I’m hoping I can get him back to breast 100%… I might have to use an SNS at first, since he’ll be used to “easy milk” from bottles and might not have patience to wait for a let down. The SNS will reward him for sucking properly, with milk right away, and its slow flow will make sure that he will continue to work for the milk if he is hungry.

This is just the beginning, but I wanted to put everything “out there” so you all know what is going on with us right now. If I don’t answer the phone when you call, it might be because I’m pumping and don’t want to have to talk over the whee-whoo, whee-whoo, whee-whoo. If I forget your birthday or don’t respond to an email right away, please know my mind is more than a bit occupied right now. 

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Everything’s going to be okay. But in the meantime, we are working very hard.

And laziness certainly is NOT the reason I breastfeed.