GOING BACK TO WORK - Combining breast and bottle feeding

Carrie: I plan to breastfeed solely for six weeks. However, I want to go back to work after my six weeks are up, so I want to put breastmilk into a bottle only, I am not sure how to introduce the bottle to my infant. I don't know how long I should wait before I introduce it either. Could you please let me know the best ways of doing this?

Anne: Hi Carrie! Congratulations on your decision to continue nursing after you return to work. It's a real labor of love, but well worth all the effort.

When you say that you want put the milk in bottles only, does that mean that you are not going to pump while you are at work? If so, then it is going to be very difficult to maintain your milk supply for a baby who is only six weeks old. Or do you mean that you plan to exclusively pump after you return to work and not put the baby on the breast at all? That is also going to present difficulties.

The first month or so of nursing are a time of establishing and building your supply. At six weeks, you will have a good supply built up and your baby should be nursing efficiently. In order to establish an adequate milk supply, your newborn will nurse frequently (10-12 times or more in each 24 hour period in the beginning). If you return to work full time and your breasts don't receive any stimulation for an extended period of time each day, your supply is going to diminish.

There is no way to predict what any baby will do in a specific situation. Some older babies who are eating solids and only nursing a few times a day will do well with the "nursing when you're together and using formula when you can't nurse" regimen. Others will begin to lose interest when your supply starts to drop.

Young babies who are totally dependent on milk to meet all of their nutritional needs are more likely to become frustrated and unwilling to go on the breast at all if your supply drops dramatically. It would be much easier to continue nursing after you return to work if you plan to nurse when you are with your baby, and pump at least once during the workday. The articles on "Collecting and Storing Breastmilk" and "Returning to Work or School" have lots of information about what is involved in choosing a pump, expressing your milk, and preparing to return to work.

If you know that you want to have the option of giving your baby bottles, this is what I recommend:

1. At 3-4 weeks (or 2-3 weeks if you are returning to work at 6 weeks) begin pumping after feedings for 4-5 minutes if your baby had a good feeding, or 8-10 minutes if he didn’t nurse well or only nursed on one breast. This will get out the rest of the high calorie, fatty hind milk, and will not interfere with your baby’s nursing schedule. It's important to be using a good double pump. With a less efficient pump, you are going to have a problem getting out the milk that is left in the breast after a feeding. If your baby consistently only takes one breast at a feeding, you can pump the other breast, but if you do this too often, you may overstimulate your supply. Mom’s whose babies only take one side at a feeding generally have lots of milk to begin with.
2. If you are bottle-feeding a newborn, I recommend a slow-flow nipple. I like the Medela or Avent newborn nipples. A baby older than a few weeks is very unlikely to forget how to nurse just because you give him an artificial nipple, but if the flow is too fast, he may get impatient when he has to work harder at obtaining milk from the breast.
3. Try offering the bottle when your baby isn’t starving. This may seem illogical, but when a baby is frantically hungry, he is going to be in no mood to try something new. He just wants to nurse.
4. Let someone else offer the bottle at first. Your baby associates your smell and touch with nursing, and may insist on the real thing if you try to give him a bottle. You may have to leave the room entirely in order for the effort to be successful.
5. Many babies associate the cradle hold, where they are cuddled against the breast, with nursing, and will refuse to accept the bottle as a substitute. This is especially true of newborns. Although some babies will accept a bottle more readily in the cradle hold, most will do better if you prop them up on your knees or in an infant seat.
6. Offer a small amount at first. If he takes it readily, you can always offer more. If he doesn’t take it, you won’t have wasted much.
7. Make sure the nipple isn’t cold when you offer it. Many babies couldn’t care less if the milk you give them is cold (and it doesn’t cause digestive problems – that’s an old wive’s tale) but they don’t like the feel of a cold rubber nipple in their mouth. Run it under warm water before you try giving him the bottle.
8. When offering the bottle, tickle the baby’s lips gently with the nipple until he opens his mouth and explores the nipple. Don’t try to force it in his mouth.

Most babies under six weeks will take a bottle readily. Older babies sometimes get set in their ways and don't want to settle for anything but the real thing. As long as you wait until your supply is established and your baby has started gaining weight well, you should be able to combine breast and bottle feeding without much difficulty.

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GOING BACK TO WORK: Pumps and storage

Dayna: Hi Anne, I enjoyed reading about your experiences. I am 24 years old and my daughter, Leah, is almost 3 months. Breastfeeding is going great, however, pumping milk is not. When I pump, I only get 1 ounce per side. I am worried because I am returning to work in 2 weeks and I am not going to have enough bottled to get her through the days I am working (3 per week). What do you suggest? I know that when I feed her she is getting more than 1 ounce per side because she's a big baby (97th percentile), it's just when I pump I stop at exactly 1 ounce per side! I use the Avent Isis manual pump and it does give me let-down. Also, a few storage questions: 1. Is it OK to pump my milk and then put the pump and milk in the refrigerator with the bag still attached and then pump again into that same bag later on in the day? In other words, pump body temperature milk in to refrigerated milk? I want to avoid having a bunch of 2 ounce bags instead of full 4 ounce bags. 2. Can I combine two different bags of milk to make one bottle? 3. How long can I keep milk in the refrigerator before it goes bad? Thanks for your help! Dayna

Anne: Since your baby is gaining weight so well, you're probably correct in assuming that she is getting more than an ounce on each side when she nurses. One problem may be the type of pump you are using. Manual pumps are portable and relatively inexpensive. They are fine for occasional use, or for the mother who has an abundant milk supply and an efficient let-down reflex. It is important to remember that no breast pump is as efficient as the baby at removing milk, and manual pumps are generally less effective than electric ones. Typically, mothers find that they can get some milk out with a manual pump, but they don't empty the breasts completely the way a good electric pump does. The Avent manual pump is one of the very best manual pumps on the market, but it may not be adequate for expressing your milk while you are at work.

If you are going to be pumping regularly, or if time is an important consideration (as it usually is when you re pumping at work), then you might want to consider renting or buying a larger, more efficient (and more expensive) professional or hospital grade pump.

Double pumping is an important feature. Not only does it cut your pumping time in half (from 20-30 minutes with single pumping) to 10-15 minutes or less, but your prolaction levels are higher when you double pump, so you actually produce more milk in less time. This is especially important when you are pumping frequently, or when you are working and have limited break time in which to pump.

To answer your storage questions: You can pump directly into refrigerated milk as long as you add the milk within 24 hours of when the original milk was expressed. If milk has been stored at room temperature, you can pump directly into it as long as you do it within eight-ten hours. You then need to use the milk as soon as possible.

Fresh milk can be kept in the refrigerator for up to eight days. Store it toward the back. If you plan to use the milk within 8 days, don't freeze it. If you do plan to freeze it, do so within 24-48 hours of expressing it. The sooner you freeze it, the better.

You can add fresh milk to a container of frozen milk as long as there is less fresh milk than frozen. Cool the milk for 30 minutes first. For example, you can add 2oz. of fresh milk to 4oz. of frozen, but not 4oz. of fresh milk to 2oz. or frozen. You don't want it to thaw and then refreeze.

Label each container with the date it was expressed. If you are taking it to day care, put your baby's name on the label. Since the composition of human milk changes to meet your baby's needs as he grows, always use the freshest milk possible. That means using the oldest milk first.

For more detailed information about the different types of pumps and about storing your milk, see my article "Collecting and Storing Breastmilk" in the StorkNet Breastfeeding Cubby.

GOING BACK TO WORK: Milk supply?

Glenda: I'm breastfeeding as I type this! I have a 4 month old son. He weighs 20 lbs and is 28 1/2 inches. I am working full time and breastfeeding. I try to use a double pump at work but I don't seem to be getting much milk anymore. It feels like my supply has gone way down. Do you have any tips on how to build up my milk supply? My poor little guy seems hungry all the time. I try to pump at three times a day in an 8 hr period but sometimes it's just 2 times. Is that enough? Thanks, Glenda

Anne: Many mothers find that keeping their supply up when they return to work is a challenge. Most moms don't get the same stimulation when they are separated from their baby that they get when they are at home. At home, you tend to do little "snack feedings" throughout the day, and when you're at work, you tend to pump on a set schedule. Also, there is no pump on the market that is as good a healthy nursing baby, so the stimulation you get is not the same.

Solutions range from pumping more often at work (this may not be realistic for you since you are already pumping 3 times), pumping after feedings or on the other breast when baby only takes one side at home, nursing more often when you are together (especially during the night) and feeding less during the day, taking herbal supplements, using techniques to facilitate let-down when you pump, and supplementing with formula. Unfortunately, drinking water or eating a special diet doesn't have a big impact on your supply. I wish it was that easy.

Try looking at the following articles on my site: "Increasing Your Milk Supply," "Collecting and Storing Breastmilk," and "Returning to Work or School."

Continuing to nurse after you return to work can be very challenging, but it is a real labor of love and is well worth the effort. It is especially challenging when you return to work with a baby this young, but even if you end up having to supplement with formula, it is worth hanging in there. I wish you all the best, and hope the information in the articles is helpful.

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