Breastmilk production is a simple supply and demand system.  Increasing demand will increase milk production.  If medical reasons for low or reduced milk production have been ruled out, the combination of the following recommendations are well-known to establish and boost milk production.  Yield is dose related *milk removed = milk made*

1. Spend as much time as possible skin-to-skin with baby.  Wear your baby.  Share sleep with baby if you fit the ‘safe sleep 7’ guidelines.  Avoid swaddling.
2. Feed often observing earliest hunger cues, around the clock.  Wake at 3 hours if necessary during the day and at 4-5 hours at night.
3. Gently massage breasts right before latching or pumping.  Insist on a deep latch and re-latch if necessary.  Use breast compressions throughout breast feeds. Use a rental grade pump from the hospital and the correct size breast shield (flange).  Consider at-breast supplementation for a few days/weeks (with IBCLC guidance).
4. Either pump after a breast feed or pump again within an hour. Empty breasts often, every 45 minutes is not too often at first.  You are basically mimicking a growth spurt. 
5. Repeat.  Feed again.  Pump again.  More skin-to-skin…

Additional Considerations

• Limit pacifier use or discard if possible
• Try to get 1-2 more feeds in each day especially if weight gain is of concern
• Reduce baby’s crying as much as possible
• If early hunger cues were missed begin the feed alternatively with a small cup, spoon, syringe or bottle to help calm baby
• Follow immediately with a neck snuggle with baby skin to skin up under your chin
• When baby begins rooting latch again
• Include hands on pumping for maximizing milk production
• Using a warm compress will help yield more milk
• Mothers can typically express more milk with hand expression than they can express with insurance provided pumps, especially in the early days
• Boosting milk is hard work but is easier accomplished sooner after birth than later
• Continue to express your milk until your baby becomes proficient at breast 

Soon your baby will do all of the “work” and then breastfeeding becomes simpler, much more comfortable and enjoyable!
First Food For Baby is dedicated to providing access to education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.

First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Ankyloglossia, commonly referred to as tongue-tie, frequently caused by a short and/or thick lingual frenulum, usually restricts the tongue from extending beyond the gum line and also from lifting and reaching the palate, which is the tongue’s normal resting position in the mouth.  This tongue restriction, along with lip ties and sometimes buccal ties, very often interferes with breastfeeding, forcing babies to compensate which typically presents as a shallow, painful latch causing nipple damage and reduces the likelihood that breastfeeding will continue for two years as recommended by the World Health Organization. More importantly, this issue can take a toll on mothers’ health, both physically and emotionally, and mothers are not reaching their personal breastfeeding goals. Complicating matters further, even when these tethered oral tissues are recognized and released early in the life of the baby, oral restrictions may continue to interfere with breastfeeding, giving the procedure a bad name, when families feel like it “did not help” or perhaps even worsened breastfeeding symptoms. Some symptoms may continue as the baby grows, negatively influencing, feeding, sleep, growth and development. Some may even struggle with related issues their entire lives.
This simple, non-invasive and very effective procedure is failing families more often than anyone wants to admit and there are several reasons this is occurring, many of which may be avoided.
Although there are many healthcare providers whose scope of practice includes performing the frenectomy procedure, with at least as many tools and methods to perform it, the current evidence base is minimal and standards of care non-existent. No protocols or anything beyond proclaimed current best practices state how frenectomies should be performed. An Internet search for guidance quickly reveals how much the information varies, and sometimes quite drastically between providers of this procedure.
Frenectomy providers found in North America include, Dentists, ENTs, Surgeons, Physicians, Pediatricians and Family Nurse Practitioners, each with their own education and training, which can be extremely minimal when pertaining to this procedure. Currently in the US none of these specialties have any formal frenectomy education or training in place.
Some of the popular methods currently practiced to release (and revise) ties include scissors, scalpel, a variety of lasers, electro surge and other electrocautery tools, with some of these claiming to be lasers. The competency and experience of the provider with their tool of choice obviously also varies. Additionally, laser companies are unregulated and so again, without any current standards in place, this can quite literally mean someone can purchase a laser and begin performing procedures without any training on the laser just purchased. This is especially frightening when taking into consideration the many different possible setting options available with each laser.
Inexperienced and perhaps undereducated frenectomy providers, although well-meaning, may not actually release the entire restriction, sometimes admitting to ‘a conservative approach’. Others may believe they are providing a full release, which can be very difficult or impossible with certain tools like scissors, often due to bleeding and inability to see or access remaining frenulum. With these kinds of procedures it is common to use silver nitrate to cauterize and stop bleeding which can lead to suboptimal healing and restrictive scarring of the delicate tissues beneath the tongue.
When providers use hot-tipped tools to release ties, even when performed really well, there’s a very good chance that the wound will heal with significant scar tissue that can result in the return of or continued restriction.  Scar tissue is also inelastic, and has the potential for reducing tongue mobility. Use of these tools that heat up tissues also cause greater discomfort than a tool that never comes into contact with tissues, like Co2 lasers. This pain risks infant oral aversion.
Sometimes no pain management instructions are provided which can actually worsen feeding issues temporarily. Also, very often no wound management instructions are provided or even recommended for encouraging ‘healing by secondary intention’, meaning purposefully encouraging very slow, gradual healing, which is known to minimize any future restriction in tongue movement. The only exception for when active wound management exercises would not be recommended would be cases of partial release where frenulum remains and there is no diamond wound area beneath the tongue to work with.
Few providers know of or understand the necessity of physical therapy before, during and/or after the procedure and therefore may not be recommended at all. Physical therapy after any procedure is routine in order to achieve optimal outcomes. Benefits of the frenectomy procedure may be drastically reduced without this necessary component.
The timing of release also needs careful consideration especially in certain circumstances as with birth trauma and releasing tethered oral tissues in an older baby.
In cases of suboptimal healing, commonly referred to as reattachment, mothers feel the setback of returning symptoms. Providers may not see or agree with the severity in restriction or may discover other possible reasons that may seem to explain the symptoms as something else unrelated to oral restrictions. Once again, mothers and babies will continue to struggle. Sometimes a mother may insist on a second procedure while others will believe the procedure did not work to help their situation. Adding to frustration, providers may refuse to revise or redo another provider’s procedure leaving the breast feeding dyad to continue to persevere through returning or continued symptoms after initial release. For too many mothers, difficulties that resurface and cannot seem to be overcome might result in discontinuing breastfeeding or early weaning.
In some parts of the country, and with more seasoned release providers with many years of experience, second and even third procedures are not uncommon and breastfeeding ultimately succeeds. Still for many release providers, second and third revisions are often viewed negatively as reflecting poorly on adequacy of procedures being performed. Another reason may be that repeated procedures will interfere with data collected and overall success rates in their practices, which is a commonly asked question amongst release providers.
The comparing of “success rates” among peer frenectomy providers may serve no purpose. There are numerous variables to consider that make comparison impossible, inaccurate and with no validity. The sharing of unedited testimonials from families, especially those who’ve gone through the frenectomy experience more than once, however, can be very helpful and something everyone can continue to learn from.
It’s important to note that even in situations where an initial release was unsuccessful for any of the reasons previously mentioned, the revision carried out by the knowledgeable, experienced release provider is known to further reduce or resolve symptoms and supports successful breast feeding outcomes. So while a repeated procedure cannot guarantee success, as there are no guarantees in life, when a frenectomy is performed properly and adequately by well-educated and experienced release providers, and includes continued support of the family by the highly skilled interdisciplinary, breastfeeding supportive team, it is highly successful in the vast majority. Poor outcomes are virtually unheard of in situations with experienced professional provider teams.
Many well established providers of the frenectomy procedure have a deeply moving story, often stemming from their own personal experiences, that first compelled them to learn how to perform this procedure. This passion to help others to avoid the struggles they themselves may have endured, continues to drive them to learn more, share their knowledge and time freely, and collaborate with other healthcare professionals in their own communities and beyond. These few providers often have long term high breastfeeding success rates that demonstrate their passion for optimal health, proving over and over again that they care and are truly making a difference in the world of tethered oral tissues. We can be thankful for these professionals who listen to parents, nursing mothers and the symptoms they experience or continue to experience, and are willing to support them to reach their goals, whatever it takes, putting the mother and breastfeeding above all else.
First Food For Baby is dedicated to providing access to education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.

First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Congratulations on the birth of your new baby! You don’t have to worry whether your healthy full term, exclusively breast feeding newborn is nursing well the first week of life after birth. This will be apparent with adequate diaper output.  Simply put, what goes in, must come out.  On day one there will need to be at least one wet diaper during the very first 24 hours.  A wet diaper is the equivalent of three tablespoons of liquid, so it should feel heavy.  This first wet diaper may be colored red or orange, which is normal.  The rest of the wet diapers will all be colorless.  There will also be some large and small poops.  Look for at least one poopy diaper that is larger than a large coin.  It will be black and sticky.
On the second day look for at least two heavy wet colorless diapers and at least two sizable poopy diapers.  The color of the poop may start to change from black to green and be kind of a pasty consistency.
By the third day the wet diaper count should be at least three and same for the poopy diapers.  So look for three poopy diapers that are more green than black.
The fourth day continues to increase in the same way with at least four wet diapers, and normal poopy diapers should continue to be three to four, but changing to yellow or mustard color.
Look for at least five wet diapers on day five, and three to four poopy diapers that will be yellow in color and can be runny or seedy as milk comes in and matures.
Days six and seven may see diapers increase to as many as a dozen, maybe even more, but look for at least six to eight heavy wet diapers.  Poopy diapers typically remain around three every day until about six weeks, which is the minimum to be expected but may also count to a dozen especially if antibiotics were given, a stool softener is taken or the baby seems to need to eat often.  Babies do need to eat between every hour to two and a half hours, with one slightly longer stretch somewhere during a 24 hour period.
Baby behavior that indicates satiety often includes self-detachment from the breast anywhere between 20 to 40 minutes (feeds will get shorter), contentment between feeds, including relaxed hands as opposed to mouthing their little fists, and will be ready for the next feed between one to two and a half hours at most. Bottle fed babies typically go three hours between feeds, usually due to overfeeding which can be difficult to avoid.
Babies demonstrating these things will gain between five and seven ounces after the first week, every week, sometimes more, surpassing their birth weight before their second week of life.  The Pediatrician will monitor weight gain closely, watching baby’s growth curve.  Always trust your instincts as the expert on your baby.  Always reach out to your Pediatrician for any concerns.
Please note that breastfeeding also needs to be pain-free and comfortable. Although common, pain with nursing is never considered normal, but rather an indication that something is not quite right. Do not accept pain as part of your nursing journey no matter what anyone says and seek the assistance of a knowledgeable Lactation Consultant (IBCLC).
First Food For Baby is dedicated to providing access to education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.

First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Tongue-tie is the non-medical term for ankyloglossia, which comes from the Greek words ankylos, meaning “curved” or “crooked” and glossa meaning “tongue”.  A relatively common congenital anomaly, tongue-tie impedes tongue function with an unusually thick, tight, or short lingual frenulum. (Hall DM, 2005)
Tongue-tie can disrupt breastfeeding causing many issues from occasional discomfort to extreme pain in a mother.  Mothers often report raw, cracked and bleeding nipples and lip blistering is very common in babies, whether breast or bottle-fed. (Genna, 2013)  Babies usually suffer from a myriad of issues that often include reduced sleep, slow weight gain, failure to thrive, colic and digestive issues and can be plagued with hiccups and reflux symptoms.
When identified early, many of these issues may be avoided with a simple procedure, called frenectomy, when performed by an experienced, knowledgeable medical provider and so long as specific and adequate aftercare is also carried out. (Praborini, 2015)  Even older children benefit from this procedure. (Baxter, 2020)
There are several different methods used to release tongue, lip and buccal-ties, the most common being scissors, dating back to the 1600’s (Obladen, 2010), and more commonly used today are electrically charged lasers such as the Co2 Laser. (Fernando, 1998) There is much controversy surrounding the different tools and methods used to release ties.  However, one of the most important aspects is how thorough the release of the ties. (Hall DM, 2005) 
Clear evidence suggests breastfeeding success appears to be most often directly related to the full release of the tie or ties.  The fibrous attachment beneath the tongue must be released at least enough that it becomes a diamond shape allowing far greater tongue movement including the ability to lift which is necessary and vital in breastfeeding and proper swallowing. (Genna, 2013)
Once the tongue has been fully released it then becomes the responsibility of parents and caregivers supported by their healthcare provider, usually an IBCLC, to keep the area from healing too quickly allowing for healing by secondary intention. (Devishree, 2012)  This can be difficult since the mouth heals very quickly, therefore instructions for aftercare management of healing should be carefully followed. 
Many experts agree and recommend the release of tongue and/or lip-ties that restrict proper function.  It is current best practice to incorporate appropriate physical therapy for commonly associated and sometimes very obvious (but not always) but often restricted neck and jaw muscle tension that nearly always exists due to the nature of ties. (Genna, 2013), (Bickford, 2014)
Mothers can experience all of the many health benefits of breastfeeding their babies if they ‘insist on diamonds’, and are consistent with aftercare as it can be considered a shortcut to comfortable and successful breastfeeding. 


René Moore is a registered IBCLC in private practice in Phoenix Arizona.  Her interest and passion for breastfeeding began in 1996 upon becoming a mother.  In 2000 she became a La Leche League Leader and still leads local meetings for groups she started in her area, then also became an International Board Certified Lactation Consultant to be able to help more mothers, babies and families.  She’s been performing in-home lactation consultation visits for well over a decade and regularly attends procedures when requested by parents and welcomed by providers.
She believes that restrictive tongue/lip-ties are much more common than statistics suggest and that there are likely millions of adults completely unaware that issues they might be suffering with may be associated with undetected or under diagnosed tethered oral tissues.
First Food For Baby is dedicated to providing access to education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.
References
1. Hall DM, Renfrew MJ. Tongue tie: Common problem or old wives’ tale? Archives of Disease in Childhood 2005. 90:12-11-1215. https://pubmed.ncbi.nlm.nih.gov/16301545/
2. Watson Genna, C. (2008). Supporting Sucking Skills in Breastfeeding Infants. Sudbury, MA: Jones and Bartlett.
3. Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding American Academy of Pediatrics 2004 1-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082757/
4. Clinical Lactation, 2015, 6(1), http://dx.doi.org/10.1891/2158-0782.6.1.9
5.Richard Baxter, DMD, MS1 , Robyn Merkel-Walsh, MA, CCC-SLP/COM2,3, Barbara Stark Baxter, MD, FACP4, Ashley Lashley, BS1, and Nicholas R. Rendell, MSc, PhD5 Clin Pediatr (Phila). 2020 Sep; 59(9-10):885-892. doi: 10.1177/0009922820928055. Epub 2020 May 28. Functional Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release: A Prospective Cohort Study, https://pubmed.ncbi.nlm.nih.gov/32462918/
6. Northcutt, ME. Overview: The Lingual Frenum. JCO, 43(9), 557-565. Fernando C. Tongue Tie – From Confusion to Clarity;A Guide to the Diagnosis and Treatment of Ankyloglossia. Tandem Publications, ISBN: 0646352547
7. http://nurturedchild.ca/index.php/breastfeeding/challenges/what-to-expect-after-tongue-tie-and-lip-tie-release/
8.  J Clin Diagn Res. 2012 Nov; 6(9): 1587–1592. Published online 2012 Nov15. doi: 10.7860/JCDR/2012/4089.2572
First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Mastitus definition: Inflammation of a mammary gland, usually caused by infection.
Breast infection occurs with inadequate or infrequent milk removal, or both. Symptoms typically begin with a firm knotty area in one part of one breast that will be tender to the touch, but can occur in both breasts. The area will then turn red and become very painful to the touch and some mothers will also experience fever and/or chills, similar to the flu. If infection is deep within the breast, along the chest wall, there may not be any visible skin reddening.
Recovery from a breast infection should always include anti-inflammatory medication, frequent, thorough milk removal using warmth and breast massage, rest and may even require antibiotics. It is also important to determine the underlying cause to avoid recurrence and always ensure baby is correctly latching. Recurring breast infections may negatively influence milk production even in future breastfeeding relationships.
First Food For Baby is dedicated to providing access to education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.

First Food For Baby  Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Tongue tie (also referred to as Ankyloglossia, Short Frenulum, or Tethered Oral Tissues) is a short and sometimes thick lingual frenulum that restricts the mobility of the tongue, particularly it’s ability to lift to the palate, and is nearly always associated with a lip tie.  Often times a tongue tie also restricts the tongue from extending beyond the lower gum line or to lift entirely during suckling and swallowing. This can significantly impact feeding and may cause the baby to use compensatory, abnormal tongue and jaw movements during breast or bottle feeding. Tongue humping, thrusting and chomping on the breast or bottle for stability commonly occurs and any of these or other compensations are known to lead to developmental issues as the baby matures. Those most common are swallowing disorders, often leading to digestive issues, speech, dental, breathing and issues with sleep that may last a lifetime if not treated.
First Food For Baby is dedicated to providing education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.
First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com

Infants born prematurely or late preterm are at risk for feeding difficulties and may take more time to become proficient at breast. Infants born with neurological deficits are more likely to be diagnosed by the pediatrician at birth, but not always, and can influence breastfeeding or feeding in general.
Other common reasons for breastfeeding incompetency and struggle are structural issues impacting function that are not always easily identified without vast experience and a keen eye. Anatomical issues such as tongue tie are now being recognized earlier enabling providers to establish care plans that protect mothers milk production establishing, as well as supporting the overall health of the mother/baby dyad while working to resolve related issues. Interestingly, American Pediatricians don’t receive education in these areas and therefore are very likely to disregard the possibility of ties. Breastfeeding education is also not provided for or required of Pediatricians. It shouldn’t come as a surprise that families are struggling.
First Food For Baby is dedicated to providing education and lactation care to breastfeeding families. If you are struggling with breastfeeding or have questions, First Food For Baby is here to help.
René Moore is a registered IBCLC in private practice in Phoenix Arizona.  Her interest and passion for breastfeeding began in 1996 upon becoming a mother.  In 2000 she became a La Leche League Leader and still leads local meetings for groups she started in her area, then also became an International Board Certified Lactation Consultant to be able to help more mothers, babies and families.  She’s been performing in-home lactation consultation visits for well over a decade and regularly attends procedures when requested by parents and welcomed by providers.
First Food For Baby Copyright © 2011 – All Rights Reserved / May be used with permission: rene@firstfoodforbaby.com