NURSING & PUMPING: Part 1

A Conversation with Corky Harvey, IBCLC & Callan, Editor

Corky Harvey, MS, RN, IBCLC is the co-founder of The Pump Station & Nurtury®, the first new parent resource center of its kind in Santa Monica, CA. She is a registered nurse with a master's degree in maternal/newborn nursing, a certified Happiest Baby on the Block educator, and was a long-time Childbirth Educator.

In part one of our interview series, she and Motherhood Editor Callan, who was nursing her 15-month-old daughter, chat about what a lactation consultant is, the importance of breastfeeding support groups, and the 411 on nipple confusion.

CALLAN: Can you explain what services a lactation consultant provides, why a mother might want to consult one, and what you can expect during your first consultation?
CORKY: First and foremost, I think she provides tremendous support. So many parents struggle because they think that breastfeeding is natural. And although the physiology of it is natural, it can be kind of mucked up if people don't know what they're doing. Lactation consultants should have the educational piece, as well as the heart for it to be there to support people no matter what. Secondly, they should have hand skills. And I think this is a variable thing within the organization, especially depending on how much experience a person has going in. But she should have good hand skills and skills to help mothers with each individual problem within breastfeeding. We like to say: It can be pretty easy, but it can also be pretty tough.

And I think that's a fair approach. There's evidence to support that every woman could use lactation support and that women who seek lactation consultants have more success with their breastfeeding. I did a support group yesterday that got eight moms in there and every single one of them was experiencing some level of difficulty with their breastfeeding. Unfortunately, hospitals don't have the budget or see that as a priority. So, we don't have as much lactation consulting available within the hospital setting or even after women get home.

What if the baby isn't latching or a mother has a lot of pain? Maybe she thinks her milk supply isn't there. A baby isn't gaining weight. It’s a myriad of things. And it depends on what phase of breastfeeding you're talking about. But in the early days, what we see the most is not nipple pain. That's number two, probably. What is number one is low milk supply concerns, something quite being right, or lack of latch - that's really high.

CALLAN: What does a typical consultation look like? What can new moms expect?
CORKY: It depends on your situation and what you're there for. But in our situation, it always includes a history, and it includes an evaluation of what the problem is, and how the mother feels about that problem. In other words, what makes her think her milk supply is low? And then it would include an evaluation for a weight check. A complete evaluation of the baby, the baby's mouth, how the baby looks, and then an evaluation of the mother – what her breasts look like, what her nipples look like, how they feel. So, it's a complete physical with a history. And our group is almost exclusively RNs, so we have that skill set with good evaluation and they can expect to have our help and hopefully leave with a plan.

CALLAN: I sought out a consultant after I had my daughter very early – I needed the reassurance of somebody telling me, you're doing this right. And yes, your baby's getting food - I needed that weight checked to make myself not so crazy.
CORKY: I just wrote a blog for this yesterday. Getting to know where your helpers are before you have the baby, getting as much help as you possibly can in the hospital, and then calling a consultant immediately upon discharge. For instance, milk supply, that's something we need to address really early. We can address it later, but the success rate is higher with the earlier we can intervene, interfere, or intercede.

CALLAN: Can you tell us more about breastfeeding support groups?
CORKY: Women need community. And women really need the support of each other. And in a support group, you'd be amazed how many of the questions are asked and answered by other mothers. Yesterday, I had a one-week-old baby who was struggling with low milk supply, and two of the mothers have had that same problem. And they were able to say, “Here's what I did. Here's where I am now. Hang in.” We need that community around new mothers.

Even one hundred years ago, women lived in communities where they met in each other's kitchens and supported each other. Now we're alone in our apartments going, “What the hell's wrong with me?” The consultants, they're saying, “Yeah, you need to be pumping a little bit more than that, because here's the deal.” The support groups are really, really vital as are Mommy and Me's, where you can have that support of a roomful of women who are saying, “Well, my baby is like that too, and my baby never did that.” It just is such a vital piece.

CALLAN: When should moms begin pumping? When I had my daughter, I questioned if I should have been pumping as I was breastfeeding. But she cluster fed for a month, so I was like, when can I possibly pump?
CORKY: It so depends on the circumstance. If your baby latches right from the beginning and is nursing well - like your baby did - and the baby's gaining weight, well, you shouldn't have to pump. Then, we would then suggest to that particular mother that she begin pumping when she wants to give a bottle, but somewhere between two and four weeks, because if you wait too long, some babies will not take a bottle and the partner often really wants to be involved. We would say if you could give breastfeeding on the breast about two weeks, so the baby really establishes supply and has that system down before you introduce a bottle, then start pumping somewhere close to the end of the first week to begin to play with your pump and see how it works so that you have a bottle by two weeks to let your partner enjoy doing that.

To the mother whose baby isn't latching or is separated from her in the NICU, she needs to start pumping day one within the first six to eight hours after birth and be fastidious with her pumping at least every two to three hours. Because, again, it's the removal of milk that drives milk supply. If we're not doing that, we're not going to have a good supply. And then we have mothers with low supply who are nursing, but they're pumping after every breastfeeding. In breastfeeding - if your baby is being supplemented, you have to pump, otherwise the milk supply cannot come up. It'll go down. That’s a piece a lot of moms don't hear and don't know. And then they're really in trouble with low milk supply.

Then there's the mothers that have huge supply and they're only pumping every other day when their partner is giving a bottle because they're milk goes too high. And the mother who's going to go back to work is pumping enough for her partner to give a bottle every three days, not more than once a day, so her partner could give the bottle and she can store a bit every day. We would say, again, for the mother who's not able to put her baby to breast for whatever reason, she starts immediately and for the rest of us, depending on the circumstance, somewhere between two and four weeks.

CALLAN: I'm very interested in the discussion of introducing a bottle to a breastfed baby because I had a horrible time with my daughter. I feel like I've read lots of different guidelines that we can't give them a bottle because of nipple confusion. So, I waited until she was about five weeks and I think that was too long. It then took me two months to get her to take a bottle and I had to try every bottle on the market.
CORKY: The bottom line is, if you don't have to do it because your baby took it, then good. So that's why the next baby you have - I'm assuming you have one child - you will start at two weeks because of what you went through. We recommend not waiting past the fourth week – some books will say six weeks – but we see so many babies refuse the bottle around that third, fourth week. You've got to stay consistent.

The other opposite is also true, though. If babies get lots of bottles, they'll refuse the breast oftentimes. We say one bottle a day maximum. That said, we get that life happens and there might be a day when you had to go to the doctor or something and you gave two bottles. But don't do that consistently. We have moms who have to go back to work. And it is just one of the biggest frustrations. And even then, we will have some babies who will still refuse at about three months. They get so smart.

By the way, it's a myth that if you starve a baby, they'll finally take it. That is a myth and its heart wrenching, and you just can't do that. And it's also a myth that it should be someone else other than the mother at that phase trying to work it out with baby. The mother really has the best skill set and usually more patience.

CALLAN: I did everything wrong then, because it was a week until I had to go back to work, and she still wasn't taking a bottle. So, I did the ‘I'm dumping you at grandma's house and hopefully you'll take a bottle from her.’ She finally did, but I had to drop off five different bottles and the bottle she ended up taking was the Nanobébé that looks like a boob.
CORKY: I don't know that you did anything wrong. I think you did what you needed to do at the time, and it finally worked.

CALLAN: Yeah. It was hard though. I was really scared. I was like, am I going to have to quit my job because this baby won't eat? I was trying to think of any solution.
CORKY: She didn't starve. She went to grandma’s. She kept trying. She got a little bit and finally she said, OK. The unfortunate thing is babies are too young at that age to actually have a learning experience. And I know it still hurts you to think about it. So next baby, you'll start probably at two weeks.

CALLAN: Can you talk about what nipple confusion is and how that can happen?
CORKY: I don't think most lactation consultants like that term. It's really not so much about the nipple, it's about the flow. We reference it as flow preferencing. A bottle is immediate, constant, and often fast. And a breast is not. A breast has to be suckled before it releases milk. And that may take a minute or so before milk flows. It’s a hormonal response called a letdown reflex or, in medical terms, the milk injection reflex. When a baby suckles at the breast, it sends a message to the brain, the brain tells the pituitary to release oxytocin into the bloodstream. When it comes to the breast and hits the breast, there's a little muscle band around every cell in the breast where the milk is made and it contracts.

A baby who's getting lots of bottles doesn't know that…they get used to that flow of immediacy. And then they're on the breast just pulling off like, where's the milk? Another concept is that the breast ebbs and flows, so that oxytocin surge happens, milk flows, and then goes quiet. Our pituitary doesn't just pour it out, it pulses it out while the baby's sucking. This is healthy for babies because it gives them a respite from the heavy flow, it gives them a chance to sort of breathe.
Sometimes we have no choice - they can't latch at first or they're in the NICU or whatever the reason. And so we try to encourage moms to relax about that, but to do the best they can to not use bottles in the first two weeks, if possible.

Wherever we can, we say no bottles and no pacifiers. But we're not anti-pacifiers. If you need to use one, don't get all worked up about it, do it, but be sort of minimal as that baby's learning to suckle at the breast. I get upset because it's one of the wonderful things about the breast, is that can be used to calm your baby and it should be used that way, too. And it also helps drive milk supply, etc. So, it's wonderful.

CALLAN: So why might some women choose to exclusively pump?

CORKY: It’s called EPing - exclusively pumping. Some women do it because they can't get the babies to latch. Some women just like it better because it's more convenient to them. Some women like to know how much milk their babies are getting. So there's a variety of reasons why.

I have a woman in my support group right now doing it because her baby is tongue tied, which did not get fixed, and the baby could not remove milk properly from the breast and was losing weight. So, she went to EPing. Another mother chose to exclusively pump because her baby never latched effectively. Exclusively pumping is tricky, but for some women, it's an answer and we support them fully.

CALLAN: Do you have a recommended pump or do they all kind of work equally?

CORKY: We do have several that we like the best. Know that none of the pumps coming out of insurance companies are equal to what we call the clinical grade pumps. So, the best clinical grade pump is the Medela Symphony. I beg mothers in support groups who have low supplies to please go rent a Symphony because it is more effective. I'm not mechanical enough to tell you all the ins and outs of it, but it is the smoothest, quietest, most wonderful pump on the planet. So, anybody with a milk supply issue, a breastfeeding issue, or twins or babies in the NICU should be on the clinical grade pump. Ameda is also a good clinical grade pump. Some of those little pumps say they’re hospital grade, but the FDA would disagree with that. Spectra is not clinical grade, but it is a wonderful pump.

And Medela has a new pump that's awesome. It's called the Freestyle Flex. It’s not coming through the insurance companies yet, but many mothers can get a voucher or pay a little extra money and get it. In-bra pumps are important for some women who could not otherwise pump at all - say they're in a workplace where they could do the in-bra pump - but I would use them as a supplementary pump.

CALLAN: Flanges…these was super confusing to me when I first started pumping because of the sizes. This is the same thing with the nipple shields, so how do I know what size I am?

CORKY: We do have a piece that one of our consultants wrote that I think is really helpful. We really dislike going down to 15 and 18 milimeters...even twenty ones for me. I almost never recommend them because here's the thing: if your nipple is stuck and the pump sucks right on your nipple or nipple base, it can't remove milk. Remember that a baby needs to have their jaws higher on that breast, if they're right on the nipple, they cut off their supply. So, I have seen women lose their milk on these smaller sizes of flanges. I think mothers should have a variety of sizes, play with them a little bit and see what works most effectively for them. I even think switching it up a little bit occasionally. So Medela has always come with 24mms, but easily you can buy 27mms, 30mms and 36mms. Spectra comes with 24mms and 28mms. I think it's nice to have those two choices.

I would encourage all mothers to get more than one size, but to be awfully careful about going too small because even those pumps are mostly suction as that nipple pulls in, there is some positive pressure on that area, and it needs to be on the area where the baby would have their jaws. Another thing is to grease with nipple cream, not lanolin. Lanolin is too sticky. I'm not saying it's bad, it's just sticky.

CALLAN: How long should you pump for?

CORKY: We think the maximum is usually 20 minutes. I had a mom call me last night that pumped for 45 minutes. She was extremely full, and she said it kept coming and there's always exceptions, but usually 15 to 20 is what we would recommend. For breastfeeding, it's always been said to do about ten to twenty minutes on each side. And the mom with big volume, we ask her to start pumping to ounces rather than time, whereas mothers with lower supply, we don't have them pump to ounces, we have them pump to time. So, it's a little bit different for each mother. That's the thing about breastfeeding and why women need so much help, because it's pretty gray depending on your circumstance.

CALLAN: Do you have a number one piece of advice that you give to every new mom when they start breastfeeding?

CORKY: In my support groups, we start off with - what is the one thing a mother is going to need to be a successful breastfeeder other than breast and a baby? And the answer to that is the intention to breastfeed. And I think subsequent to that is knowledge.

Before you even nurse, to me, it’s shooting yourself right in the foot to not take a breastfeeding class of some kind. Ours are three hours long with the partner and you're on Zoom. You can bring your mom, or whoever. And then my next piece of advice would be to get help as soon as you need it and get those questions answered. Have somebody like me on speed dial. And I give them my cell phone so they can text me and ask me a question. Do not wait. If you’re on day three of having struggles, you should be online making an appointment to get a lactation consultation. Get educated, have a great attitude, and stick to it because women will say all the time it takes a few weeks. Hang in there.

I had mother say, my baby's now twelve weeks or so and I love breastfeeding, but it took a while to get there. And some women have no trouble at all! Of course, I want to make sure that we hear that. Know where your help is before you go into labor because it's not the same everywhere.

CALLAN: In conversations with mothers and myself, we felt like even though some of us did take classes, we still thought this would come to us super easily. And most of us had many struggles. You just don't realize how many questions you're going to have and how awkward and uncomfortable it can feel at first.

CORKY: We say that moms think it's going to be natural and intuitive, and we don't think it is. So, I think of natural the same way as I think of intuitive. The nurturing of our babies usually comes easily, I mean some women take a little time to come to that too - loving your baby right away. But I think it can be intuitive. I just think we don't trust ourselves anymore because we haven't had models to follow because we lost breastfeeding in this culture almost completely.

Now we're getting back to that. Let me give you an example. When your baby is born and you deliver the baby and the placenta, now there's a natural hormonal shift that takes place when the placenta hormones go away. And that's going to happen naturally. That kicks us into the change that brings our milk supply. It allows the prolacta, the hormone that makes us make milk, to rise high enough to bring in that milk. It shifts between the second and the fifth day from that natural sequence of hormonal shift to now milk supply being driven by the removal of milk. So, if the mother doesn't know that and her baby isn't nursing well, she already goes into a risk point for a low milk supply.

CALLAN: What are some things that brand new moms can expect when they're beginning to breastfeed?

CORKY: A little bit about hormones: the cramping is a positive sign that your oxytocin is working well. So, when a baby suckles, that sends a message to the brain, the brain releases oxytocin and prolactin into the bloodstream, they come back to the breast. So that little band of muscle around every cell in your breast where the milk is made is the same kind of muscle that is there in your uterus. It makes your muscles contract, squirting that milk out of your cell, into the ductal system, to the baby. But it also makes your uterus contract. It makes your brain fall in love with your baby. But the uterine contraction is critically important to women not having postpartum bleeding or postpartum hemorrhage. It’s nature's way of protecting the mother.

Your nipples will also be tender for sure. But too much is not normal, it means that the baby was not latched deeply on the breast. And there's some contributing factors like could it be a tongue tie? But in 99% of the cases, it's that the baby's not on correctly. And hopefully the nurses in the hospital are able to teach you to tip the head back, start lower down here with that lower jaw and come around so that baby is landing deeply in the mouth.

Scabbed, sore, bleeding nipples that mothers have is also not normal. Something is wrong. If that's what you're experiencing, you are in that category of needing help pronto. But to expect it to feel like a real tender breast when the baby latches and sucks for the first few times on each side, it's a little breath-catching but two minutes in and you're settled.

CALLAN: I remember the nurses at the hospital asked me, has your milk come in? And I'm like I don't know. How do I know that?

CORKY: Between the days of two and five - after that hormonal shift takes place - the breasts swell, it's not just milk, it's called engorgement. Engorgement only really refers to that base. It's increased blood flow to the breast as well as some fluid retention that's happening post birth, but it is also milk. So, when that breast swells day two to five, your milk is coming in. Severe engorgement, though, is tough because it's harder for babies to grasp. Nursing really affects when your milk comes in and how high it will go. The biggest problem with engorgement is making sure the baby's latching and removing milk.

If that isn't happening, then a mother would need to pump through that phase as well. But that's when you know that your milk is increasing, is that if a mother has none of that, no breast changes in pregnancy, no engorgement, she's at risk for a low supply and she's rare, but she's at risk.

CALLAN: How do you know if you have a good versus a bad latch?

CORKY: A baby with a good latch would sustain the latch and not come off. So if the mother calls and says, “my baby's not nursing very well…he latches and then comes off in three seconds.” That baby was not latched at all or very little. So the baby should latch and sustain the latch. Rest, go, rest, go, rest, go without coming off the breast. So that would be a good latch.

CALLAN: Is there any specific position that you recommend to women or special tips for getting comfortable while breastfeeding?

CORKY: I nursed all three of my children with never having a nursing pillow. Of course, they can be nice, but they can also be worse than not having a pillow because the natural position of a baby is turned around - they're under my second breast. We love a backrest. The breastfeeding pillow called My Brest Friend has a very minimal one. And moms strap it on too high, but it can be used well. I'm not heavy breasted so I didn't have to do the rolled up washcloth under my breast thing, but you can.

Do a deep latch with the other hand on the breast, tip the head back, and come up from the bottom. That way, once the baby settles in, you can shift arms. I see a lot of moms leaning forward. You don't need to do that once the baby's on the right with you.

My favorite position for newborns is the football hold because you have a lot of good control that way, especially for difficult latches, etc. I think the football hold with a couple of pillows at your side with your baby's face right under the breast is my favorite.

CALLAN: I was a fan of the football hold for my daughter's first two weeks. I had a C-section, so I thought it was more comfortable to not have her on me.

CORKY: Unless a woman is incredibly small breasted I think it is the easiest position for to get comfortable, to get good at it. And so I taught all mothers as I rounded in the hospital in my early career how to do that.

CALLAN: Can you share why some women or babies may not be able to breastfeed longterm?

CORKY: There are probably around five percent, maybe more, of women who cannot make enough milk for their babies. Some of them may have had damage to their breasts. I've seen women who were burned, who got bit by a horse, who were in car accidents, had cancer…

And we see women with hormonal issues, like sometimes women with polycystic ovarian don't make enough milk and sometimes they make tons of milk. So don't think of that as a negative to start with. And we see women with breasts that weren't developed or who've had reduction surgery, so there are all kinds of women in those categories who might not make enough milk. But I have seen such miraculous work by mothers where they double the stimulation and bring their supply to the maximum. And we just put our arms around them, literally and figuratively, and try to help them achieve as much of their goal as possible.

Another reason would be if a mother had to go on a medication that was contraindicated for breastfeeding. Again, I've seen women who have breast cancer or multiple sclerosis. And I would tell you also that women sometimes actually inadvertently cause a little milk supply and are able to continue by using birth control. So estrogenic will take your milk out.

Another thing that can affect low supply is sleep training babies. Most babies would sleep through the night, which is considered six hours. Maybe they go to bed at seven thirty, but they get up at 3:30, feed once, and go back to sleep. That's an important feed for babies. My babies did that even past a year, but our culture thinks you're supposed to sleep 12 hours and they're not.

Some reasons are primary and can't be helped. Others are secondary. They're actually something we might have been able to do differently. Can I just say one of my great passions now is to help keep women on the long road because we now know there are so many benefits for women to breastfeed. It’s not just for babies, it's for us.

CALLAN: Can you talk about clogged ducts and how to resolve them?

CORKY: The leading cause of mastitis isn't clogged ducts, it’s an open wound in your nipple. But clogged ducts can lead to mastitis. Clogged ducts are caused usually by going too long between feedings. And sometimes you never know why. But what we would immediately do is try to get it out of there so we would double up on your nursing or we would breastfeed and pump afterwards. We would use heat to sort of open it up, lots and lots of massage or vibration, moving it toward the nipple area. We might put a woman who's getting these repeatedly on sunflower lecithin because it makes things more slippery and is not harmful.

Engorgement's the whole breast, and our biggest milk producing areas on the outside of our breast. So they're more commonly there, but they can happen anywhere. We sometimes send women for ultrasound treatments to try to loosen that and get it to come out when it becomes mastitis.

CALLAN: Any other words of wisdom or pieces of advice that you would want to share with our moms?

CORKY: It's worth it, to stay in the program and do everything you can to get the help you need to be successful with your breastfeeding because it's going to pay off for you and your baby. And at this time, where disease fighting is so important, it gives your baby that huge immunity that they need so desperately. And it becomes a peaceful thing.

There is help for you. That's what I would say. And I'm so glad that you guys are focusing on this important thing. It is so important.