This past week, I attended the Nursing Mothers' Council Lactation Conference with Dr. Jack Newman, a world renowned lactation expert. Dr Newman was a wealth of knowledge and I learned a lot, but there was one statement he made that I disagree with: he doesn't "believe" in oversupply. While I concede that many of the symptoms of oversupply overlap with other breastfeeding issues, there is an oversupply paradigm that some mother-baby dyads fit. 

Dr. Newman brought up the example of the mother who is concerned about the color of her baby's poop, specifically that it's green. Of course in and of itself, green poop doesn't mean much of anything. When I see a characteristic case of oversupply, the poop isn't just green, it may also be "frothy" (have bubbles and a sort of whipped appearance), explosive, and acidic, causing diaper rash. In addition, the baby:

• Has GI discomfort and gas, causing fussiness

• Often has a good latch and is obviously swallowing lots of milk (which can be observed by watching the bottom of the chin-- it should pop out during each pause between sucks, demonstrating milk flow into the esophagus)

• And here is the big one (no pun intended): is gaining A LOT of weight very rapidly. Case in point, here is my daughter, just after birth (8 lbs, 2 oz), versus exactly two months later and approaching the top of the growth charts.

Rolls for days! I love me a fat baby, but she also exhibited all of the above signs and was clearly uncomfortable. Normally a baby nurses and gets a mix of foremilk and hindmilk during a feeding. With oversupply, there is so much milk there that the baby winds up with a plethora of foremilk, which contains lots of lactose sugars, and doesn't get to much of the hindmilk, which contains the enzyme required to break down lactos: lactaze. The problem with oversupply is that all that undigested lactose makes babies uncomfortable and what do they want to do when they are uncomfortable? Nurse, of course! It quickly becomes a downward spiral.

In addition to the above symptoms in baby, the mother might also experience: 

• Fast letdown (milk sprays like crazy when it starts flowing, baby has a hard time keeping up)

• Engorgement between feedings

• Blocked ducts or mastitis

If you and your baby match the above descriptions, you are probably wondering what to do! To start with, block feeding can be very effective at reducing milk supply to a more manageable amount. This involves feeding your baby from only one breast for a period up to four hours, before switching to the other side. I usually suggest starting with modified block feeding, which looks more like this example:

1. Start feeding on left, offer right

2. Start feeding on left, offer right

3. Start feeding on right, offer left

4. Start feeding on right, offer left

... and so on. That way your baby is still feeding on demand and getting as much milk as she desires, but you're ensuring that she gets more of the hindmilk during that second feeding by starting on the same side again. If your less-used breast becomes engorged during this process, you can express or pump just enough milk to take the edge off. 

Many mothers who have oversupply also have a fast letdown. However, a fast letdown does not necessarily indicate oversupply! Here are some additional techniques to deal with overactive letdown:

1. Nurse until letdown starts, remove baby from the breast temporarily and spray into a burp cloth

2. Hand express or pump until letdown starts, catch that milk, and then when it slows to a more manageable flow, latch baby on

3. Nurse in the "laid back" position (see below)

You can also do a modified  laid back position, where you are semi-reclined in a chair, propped with pillows. The idea is that you're making your flow work against gravity. It's also a good idea to burp your baby frequently, since fast letdown can cause baby to swallow more air.

I just want to reiterate one more time: fast letdown or green poop alone do not signify oversupply! If you don't have an uncomfortable baby with many of the other symptoms, you could be risking lowering your supply too much by block feeding. You also should not attempt block feeding before 6 weeks or so, since your body is still figuring out how much milk to make at that point. If you are the mom-baby dyad exhibiting those characteristic signs of oversupply, then block feeding for a couple weeks might help you get your supply under control so you and your baby are more comfortable. Happy feeding!

Many moms are using breast pumps these days, even if they stay home with their babies. It is wonderful that pumps have become so accessible (thanks Obama!) to women, allowing them to be more flexible with their feeding choices. I have noticed that the instructions provided for pumps are often oversimplified, leading moms to believe that pumping should be easy to figure out. Unfortunately, if not done properly, pumping can lead to unanticipated problems such as sore nipples, plugged ducts, and even mastitis.

Improper “Latch”

Just as an improperly latching your baby can cause issues with sore nipples or poor milk transfer, improperly “latching” your pump can cause similar problems. Many mothers are so eager to render their pumping technique hands free (see below for more on that), that they fail to properly line up the pump flanges. If the flange is not centered on the nipple, it can result in an improper seal and thus poor suction, as well as the edge of the flange pressing on one or more ducts. The nipple may rub on the edge of the flange, causing soreness from abrasion, and/or some parts of the breast will become emptied more than others, which can quickly lead to clogged ducts.

Put aside your pumping bustiers for now and work on getting a good pump “latch” on one side at a time. Make sure that you are lining up the flange directly on the center of your nipple. The easiest way to figure out if it’s lined up correctly is to turn the pump on for a minute and watch your breast; if it is not lined up well, you will see a pocket of air between a portion of your areola/breast and the flange. It helps to use a mirror (or cell phone in selfie mode) so you can see the underside of your breast, as well. If you see a pocket of air-- which will be apparent during the “exhale” phase of the pump motor-- turn off the pump, carefully unlatch the flange, and adjust it slightly. Repeat as many times as necessary until you get a good “latch.” In the same way that there was a learning curve with getting your baby to latch well, you will eventually only need to “latch” your pump once or twice as you get more experienced with pumping.

Flange Fit

Another aspect of pumping that many moms do not consider is the fit of the pump flanges. Most pumps come with one flange size-- 25mm for Ameda pumps or 24mm for Medela. They also typically have a smaller size and a larger size available separately for purchase-- you can find them in baby stores, pharmacies, or online. Medela has them available in small (21mm), standard (24mm), large (27mm) and extra large (30mm). Ameda offers seven sizes, four of which are comparable to Medela’s, as well as three flanges that go larger than Medela’s offerings. If you are a mom with very large nipples, an Ameda pump with CustomFit flanges might be a better choice for you.

The challenge is figuring out which flange size will work best for you. If you’ve been having nipple pain from pumping, it may be due to a sub-optimal flange fit. The flanges may be too big if you have readjusted the flange to center on your nipple several times and yet you are still getting an air pocket. Another sign that the flange is too big is if the pump is pulling a substantial amount of your areola into the flange, rather than just your nipple. The flanges may be too small if you have readjusted the flange to center on your nipple several times and yet your nipple is still right up against the edges of the flange opening and is rubbing. 

Hands On Pumping

Another pumping misconception is that you can just put the pump on, sit back, and let it do its thing. This can be true to an extent, at least when you are more experienced with pumping, but most moms find they get a lot more milk if they use a hands on approach. What this means is that you are doing breast massage and/or compression to help get the milk flowing. In fact, a 2009 study performed by the Stanford University School of Medicine showed that over eight weeks, among exclusively pumping moms of preemies, those who used hands on pumping were able to express 48% more milk than moms who used just a pump without massage.

Technique for hands on pumping varies mother to mother. For a fantastic video demonstrating several mothers’ different techniques, see Stanford University School of Medicine’s video, Maximizing Milk Production. As discussed above, I typically recommend that moms new to pumping, or those struggling with issues from pumping, focus on one breast at a time initially, without the use of hands-free bustiers.

Hands Free Pumping

Hands free pumping is not exactly the opposite of hands on pumping, although it sounds like it would be. Honestly, I don’t believe that pumping should ever be completely hands free, especially if you are prone to duct blockages or other pumping-related problems. Nonetheless, there are certainly instances in which hands free pumping is useful or even necessary, especially if you are working full time. If you must have a hands free pumping system, I recommend starting with the rubber band trick. This technique allows you to let go of the pump, but still be able to easily see your breasts so you can check for an even flange seal and also notice if milk flow has slowed down, in which case you can use breast compression/massage to speed it back up again. Note that the flanges can lose suction when you are compressing the breast, so you will need to hold them on with one hand and use the other hand to massage. The elastics simply hold the weight of the flange and bottle up.

Once you are very experienced with pumping and no longer have problems with clogged ducts or sore nipples, then you can feel free to experiment with other hands free systems, including bustiers. Just make sure that you are getting a good, even seal even with the breastfeeding bustier and be diligent about feeling your breasts for clogged ducts.

For help with pump “latch,” flange fit, learning hands on pumping, or finding a hands free solution, a lactation counselor can be a great asset to your pumping journey!

Elimination Communication (EC): A Newfangled Idea?

I'll admit that when I first heard about Elimination Communication (EC), when I was still pregnant, I thought it was a bit backward. Trying to "force" babies to hold their pee and poop until they can go on the toilet?! Then my midwife explained to me that babies naturally hold their elimination needs for a short time anyway because they don't want to pee on themselves, just like all mammals. It's not about forcing them to hold it-- it's about providing them with the opportunity to eliminate somewhere other than a diaper. We afford our pets the same opportunity... why are we short changing our children?

When you read articles about EC in the media, it's often touted as a new "fad" that is only practiced among the obsessive elite. In fact, EC isn't new at all-- the practice has been around for hundreds of years and is still the norm in non-industrialized cultures, as well as parts of Asia, where you may see toddlers wearing split crotch pants to facilitate elimination any time, anywhere. The worldwide average age for potty training is 12 months, while in the United States the average is 35 months for girls and 39 months for boys! Even in the US back in 1957, the average potty trained age was 18 months. There is nothing "new" about the practice of EC; it has just fallen out of favor thanks to the convenience of modern diapers.

This belief that EC is a fad for the elite is equally unfounded. EC is a fantastic tool for families of limited financial means, as it not only saves money on diapers for each "catch" (the term used to describe the infant's pee or poop landing in an appropriate receptacle instead of a diaper), but also most EC'ed infants become fully potty trained earlier than the US average, potentially saving a year or more worth of diapers. 

What is EC exactly?

When families ask me to explain what EC is, I often find myself describing what it is not. EC is not  conventional American potty training; it's the opposite of diaper training. EC is not coercive; it is safe and gentle. EC is not teaching your baby to hold it; it's teaching your baby to let it go. EC is not all or nothing; many families do EC part time with cloth or disposable diapers as backup. And as described above, EC is not a new concept! EC is more about training the parents (to pay attention to timing and baby's cues) than it is about training babies. Note that children over 18 months typically do not respond as well to EC and will typically do better with non-coercive potty training methods.

Benefits of EC

I have touched on some of the benefits of EC above, but here is an extensive list of ways the EC could help your family:

• Breastfeeding: Assists caregivers with assessing output, which gives clues as to adequate milk intake; may explain some fussing at the breast-- breastfeeding parent may think baby is fussing because she is done when in fact she needs to eliminate.
  
• Health: Less diaper rash/irritation, reduced chemical exposure, lower risk of UTIs/constipation, better understanding of “unexplained” colic/fussiness
  
• Bonding: encourages communication between parent and child, and between older sibling and infant
  
• Environment: Less waste from disposables, less water/detergent used for cloth, less diaper production
  
• Money: $3000/yr conventional diapering, $1000/3 yrs cloth
  
• Potty training: Much easier down the line! Often occurs much sooner than in conventionally potty trained children.
  
• Fun: exciting when you get a “catch,” more opportunities to read/play/interract with your child, feel good doing something for their health… GREAT party trick!

For my family, the main reason for starting EC was that my daughter had extremely sensitive skin and had frequent diaper rashes. EC can be a great tool for dealing with this problem, as getting some air time on the bum is often the best thing for a persistent, painful diaper rash!

Getting Started: Observation

If you're still reading, hopefully it means that I've convinced you that EC isn't a crazy concept and that it could even be beneficial to your family. But where should you start? With a newborn, you may be able to jump right in with pottying between diaper changes and upon waking. With an older infant who is already diaper trained, some legwork needs to be done first. You'll need to first observe your infant in an effort to uncover her elimination timing and cues.

Undress your baby from the waist down, dress her in a fitted cloth diaper without a waterproof cover, or dress her in a prefold with a diaper belt (they're easy to make!). You can put her in some infant leg warmers if it's cold out. Then wait and watch. When she does eliminate, ask yourself: did she just nurse? just wake up? just get put down? just get left alone for a second? You are trying to determine patterns in her elimination habits. Also note how long she goes between pees or poops. Finally, note what your baby did just prior to eliminating: did she shudder? fuss? try to crawl away? look for you? grunt? These signs are called cues and will be used in conjunction with timing to figure out when your baby needs to eliminate.

During the observation period, you can also start making your own cue sound when your baby pees or poops. Most parents use a "pshhh" or "psss" noise. Make this sound every time you see your baby eliminating, so that she starts to associate the sound with the act of peeing or pooping.

Getting Started: Pottying

Now that you know your baby's timing and cues, you can start putting him or her on the potty. I use the term "potty" pretty loosely as the receptacles used by families for EC can include the adult toilet, a child potty, a special infant "top hat" potty, a large bowl (just make sure it doesn't make it back to the kitchen!), the bathroom sink, the tub, or a patch of grass. For a newborn, the traditional EC hold may be most practical, which involves holding baby facing out, back against your chest/stomach, and your hands under baby's knees (beautifully demonstrated by my daughter and her dolly below). Older babies can sit upright on a potty, or continue to use the traditional EC hold. Only rules are that baby should be comfortable and ideally have knees above hips, and you should be comfortable and have good posture! For more on postpartum posture and its importance, see this blog post.

When you think the timing is right (upon waking from a nap is a great time to try) or you notice your baby cueing a need for elimination, place her/hold her on the appropriate receptacle and make your cue sound. If baby fusses, give it a minute; remember that many babies fuss just before eliminating and this is a new experience for her. If you get a pee, go ahead and celebrate-- just make sure it's not over the top since young babies scare easily! If you're expecting a poop as well, note that most babies will pee first, take a break, and then poop. If nothing happens, don't continue making the cue sound more than a couple times as it will start to lose its meaning. Just put a clean diaper back on (or continue naked time if you're feeling bold) and try again in 10 minutes or so.

The Process

... is not linear! There will be "misses" (the term for when baby eliminates anywhere other than the appropriate receptacle of your choosing) and there will be messes. Try not to display frustration, as this can result in more resistance from your child. Have prefolds or absorbent towels at the ready for diaper free time, as well as a natural cleaning product. I like Meyer's Clean Day All Purpose Cleaner, diluted in a spray bottle. Prefolds just happen to perfectly fit in a Swiffer Sweeper, which can save your back. EC sometimes feels like two steps forward and one step back. 

Potty pauses, during which you suddenly find yourself with more misses than catches, are common and often precede developmental milestones, teething, or illness, or coincide with a life stressor such as moving. The above picture is of my daughter around the time that she started walking; we had to think outside of (inside of?) the box to get her to stay put on the potty long enough to go! Potty strikes, during which baby completely regresses and may refuse the potty completely, can be incredibly frustrating. Trust that your baby knows what she is doing and do your best to make pottying fun again. My daughter went through a phase when she only wanted to pee in the grass "like a dog." Our neighbors were probably weirded out, but it worked. Support can be really nice to help you get through the tough phases. There are many EC groups on Facebook, Baby Center, and other forums. You can also feel free to contact me-- I've been there, I get it, I'm happy to help! Also don't forget that EC help is included as a service within my postpartum doula package. Most importantly, remember that the goal of EC is not dryness... the goal is communication and respecting your child's desire to eliminate somewhere other than on herself! 

What's a Mama To Do?

I remember when my midwives told me I would have to give up exercising, even brisk walking, for 6-8 weeks after my baby was born. I scoffed at the recommendation; I was a personal trainer with a degree in exercise science and surely this was advice for more sedentary moms. Little did I know, it would be months before I could walk without pain, let alone exercise. Three years, three physical therapists, a chiropractor, and many hours of self study on postpartum physical issues later, I am finally able to say confidently that I am healing, and I am eager to impart what I've learned about postpartum recovery to other moms.

The more I work with families, the more I hear that my experience is not uncommon. I hear from women who have had incontinence issues for years since their baby was born. Others complain of low back pain, hip pain, and even pelvic pain that just won't go away. It begs the questions, why is this happening to so many women and what can we do about it?

I believe that for many women, the main causes of postpartum chronic pain and incontinence are:

1. Improper postpartum posture and imbalanced musculature from pregnancy, exacerbated by the rigorous physical demands of parenthood. These demands include but are not limited to lifting and carrying an infant, and/or older children; babywearing with a carrier for extended periods of time; breastfeeding in sub-optimal positions; carrying diaper bags, car seats, etc.; leaning over cribs, changing tables, strollers....

2. Not knowing when postpartum pain or discomfort are within the realm of normal, and thus neglecting to seek help. When these issues go untreated, they can lead to longer term damage and chronic inflammation.
   

Assuming that your postpartum physical imitations are not due to severe pregnancy or delivery complications, addressing posture and correcting your muscle imbalances can help a lot! By working on postural alignment, learning (or re-learning) proper body mechanics, and strengthening some of the muscles that become overstretched during pregnancy, you can give your body a much needed break from repetitive overuse injury, as well as improve the ability of your pelvic floor to function properly. If your pain or incontinence issues are more severe (prolapse, a broken tailbone, pubic symphysis dislocation, etc.), or you have had these issues for more than a few months, seeking out professional help from someone who specializes in postpartum issues may also be of benefit. 

Postural Alignment: The leg bone's connected to the hip bone...

When we have proper posture, our musculoskeletal systems are able to work efficiently and in harmony; when there is a small deviation in even just one joint, it can compromise the entire system. That's why I employ a multi-point check system for postpartum posture: 

Feet → Hips/pelvis → Ribs → Neck/shoulders 

Most moms tend to have similar posture during pregnancy and postpartum. Carrying a heavy load in front of our bodies-- whether it be a pregnant belly or a child-- causes us to shift our weight back, usually via mid-upper back extension. To compensate for that motion, most people then squeeze the bum and tuck the pelvis under, shifting the hips forward. This posture leads to several problems. 

1. Mid-upper back extension stretches your rectus abdominis muscle (your "six pack" muscle), which is already overstretched from pregnancy. All women experience some degree of separation in this muscle during pregnancy and the muscle needs to be put in a shortened position in order for the fibers to reconnect; upper back extension makes that process much more difficult.

2. Posterior pelvic tilt (tucking your bum under) puts your gluteus maximus (largest butt muscle) and pelvic floor in a sub-optimal position, resulting in weakness and even deactivation of those muscles. Not only do you wind up with "mama flat butt syndrome" as I call it (low bum definition), the smaller muscles of the hip and low back have to take over, causing them to become inflamed and overly tight.

3. Shifting the hips forward causes you to hang into your hip flexors, causing overuse of those muscles and further deactivating your glutes (the hip flexors are glute antagonists).

You can see how this sort of posture could lead to low back pain, hip pain, and/or incontinence issues. Putting the main core and pelvic floor muscles at a disadvantage can really mess you up over time! Below is a picture of one of my clients, Jaime, who very generously agreed to be my posture demonstration. Note that her alignment shown here is her natural postpartum posture and that she has had some issues with hip tightness/discomfort.

I worked with Jaime using the multi-point check system, which works as follows: 

1. Feet hip distance apart and toes pointing forward.

2. Hips/pelvis un-tucked and even. Unwind your pelvis by pretending there is a string attached to your tailbone. Someone is pulling that string from above and slightly behind you. If you place your thumbs on your iliac crests (the bony pieces on the front of your hips), you will feel them move downward as your tailbone moves back and up. If you like anatomical terms, you would be moving from posterior pelvic rotation toward anterior pelvic rotation. Many people falsely believe this will cause lordosis (low back hyper-extension)-- lordosis is actually more caused by incorrect mid-upper back alignment (see next check point). Finally, check that you are not leaning into one hip or the other. Your weight should be centered over both feet.

3. Ribs drawn together. All postpartum women have some degree of abdominal separation, called diastasis recti. I'll talk more about that in a video below, but this "check point" is especially important postpartum because it draws the abdominal muscles toward each other, allowing them to heal properly. Most women, even prior to pregnancy, walk around with their upper backs extended and "nips to sky" as I like to call it. When you are pregnant, you are somewhat forced even further into this position to make room for your lungs as your baby pushes them upward. Draw those lower ribs down and together, which will then bring your mid-upper back into neutral alignment and reduce lordosis.

4. Neck/shoulders relaxed! As parents, we put enough stress on our neck and shoulders with carrying babies and bags, breastfeeding, stress.... Whenever possible, do a good old fashioned shoulder roll. Bring the shoulders up toward your ears, then roll them back and down, drawing your shoulder blades together. Drop your ear to one shoulder, then the other. Make sure you're all loosey-goosey. *Note that this motion does appose the rib motion of down and together in front, so make sure you don't undo that check point.*

5. This isn't a checkpoint per se, but I want to emphasize that no one should be sucking in her stomach all day. It's something almost all women have learned to do thanks to our society's obsession with being thin, but it really is harmful to your postural health. If you think of your core as a balloon, when you squeeze one part of it, the rest of the pressure has to go somewhere. When you suck in your "mummy tummy," that pressure is going to go into your pelvic floor, rendering it useless, and also into your ribs, making it harder to draw them together and downward. The good news is, as you strengthen your core correctly, your post-baby belly may gradually shrink.

Below you can see Jaime's "before" photo again, with a post-check point photo next to it.

At first glance, they look similar. But if you look closely at her hips and mid-back, as my friend and owner of Fierce Mama Fitness, Alexis, put it, they're in different zip codes! She looks (and reports feeling) much more comfortable after re-aligning her posture.

The one nice thing about the postural checkpoints is that they work no matter what position you are in. Some things to specifically focus on include:

• When seated or squatting, your pelvis should be slightly more un-tucked (rotated anterior) than when standing, BUT it is imperative that you then draw your rib-cage together and down over your hips or you will be putting a ton of pressure on your low back. It's not the same as leaning forward! It's a rib cage rotation, not a movement from the hips.

• When lying down, I find it can help to reach your legs out from the hips a couple times (imagine someone is pulling on each ankle) to allow your pelvis to relax into a neutral position without your ribs popping up.

• When bending over, UN-TUCK that pelvis! Bend the knees a bit and draw those ribs together. This position tends to be hardest for parents to remember, especially if they're desperately trying to ninja away from a baby sleeping in a crib.

• When baby wearing, especially on your front, the most common thing to lose is the ribs drawn together. Your body tries to go right back pregnancy posture. Don't let it happen! Keep that pelvis un-tucked and those ribs together and rotated down over your hips.

• When breastfeeding or bottle feeding, relaaaaaax those shoulders and neck please. It helps baby relax too!

Happy recovery! For more on exercises that can help these postural checkpoints "stick" and restrengthen over-stretched postpartum muscles, see Part 2: Exercises. For more on local providers who specialize in postpartum physical issues, see Part 3: Where to Get Help.

Strengthening: Core-junction junction, how's your function?*

*Apologies for the terrible rhyme

So much of how your muscles function depends on what position they're in. That's why I always teach postural alignment (see Part 1: Posture) first, exercises second. The purpose of the exercises below are two-fold: 1) They help reinforce the postural alignment check points while the body is in motion and in varied positions, and 2) They help shorten over-stretched muscles and stretch over-shortened muscles, as well as re-train neural pathways, to help the postural alignment "stick." During each of these exercises, you should be going through the postural alignment check-list repeatedly. I prefer clients take lots of time even between repetitions of the same exercise if it means that they are carefully checking that they are doing them properly. Over time, these exercises may help reduce fat, tone muscles, and tighten postpartum bellies, but that is not my focus here; you can't have fitness without function. 

The following exercises are specifically chosen and carefully described to help you return your body to pre-baby function so that you can build up to your old fitness routine without pain or injury. Aside from the piston breath exercise, which can be done daily, most moms who have the go-ahead from their doctor to resume gentle exercise should aim to do these exercises 2-3 days per week, 1-2 sets, and 10-15 repetitions per set. Start toward the lower end of these guidelines and work your way up. Say it with me this time: you can't have fitness without function! If you find yourself losing correct postural alignment or feel like you aren't using the right muscles with these exercises, take the time to stop and play around with the positioning until you get it right!

But first! Test for abdominal separation

Piston Breath

Bridges

Toe slides/taps

Bird Dogs

Squats

As you work on these strengthening and alignment exercises, start incorporating them into your daily life activities. Picking up your baby? Pretend your doing the squat exercise and go through all those checklists every time. Carrying a heavy diaper bag or car seat on one arm? Make like a bird dog and attempt to keep your pelvis and ribs aligned toward center. With proper body mechanics, you can reduce uneven loading of your joints and decrease the opportunity for inflammation and repetitive use injury.

Happy recovery! Need more help to recover from a more serious or long-lasting postpartum physical issue? See Part 3: Where to Get Help for a list of local health professionals who specialize in postpartum recovery.