Wednesday, August 27, 2014

The Nursing Mother's Triathlon, Part 2: Got Milk?

Finding time can be the most difficult logistic thing to overcome when trying to get back to your normal fitness routine as a nursing mother, but once you have that part figured out, chances are you have stumbled onto the next hurdle- keeping up your milk supply while staying active.

The Science:
Pathophysiology of lactation
Our bodies have very low estrogen and progesterone while nursing and high levels of oxytocin and prolactin for lactation. I did finally find some studies on nursing mothers who exercise, but don’t be overjoyed just yet. The most recent studies I can find are from the year 2000, and they were on lactating cows!! So please email or message me if you are a nursing mother who exercises, a formula-feeding mother who exercises, or a mother who does either but does not exercise (we need controls) and are interested in being part of a study on all of this stuff! What we know so far based on what studies have shown:

1.       Oxytocin blunts the stress response that is normally produced during exercise.
This has been shown by studies on lactating and non-lactating women and measurements of cortisol and ACTH post-exercise. Pretty neat stuff.
2.       Exercise may attenuate lactation.
Rat studies only, so we obviously need more research on this to fully understand what is going on in the human body of a lactating and exercising woman. Theoretically speaking, extreme exercise could throw off the balance of the hypothalamic-pituitary-adrenal axis that controls all of this and cause a decrease in milk supply. I'm sure it's not true for every woman, since there are women out there doing Ironman races as nursing moms...not too many, but they're out there.
3.       Nursing mothers take longer to lose pregnancy weight than formula-feeding mothers.
Studies have shown that nursing mothers eat more calories than formula-feeding moms, and it is postulated that this is why nursing mothers take longer to lose baby weight than formula-feeding moms (6-9 months as opposed to 2-4 months). However, no studies have looked at weight gain in the baby as a measure of whether lactating mothers are or are not taking in adequate calories. 

Showing that lactating women retain pregnancy weight gain longer than formula-feeding mothers due to increased calorie intake is only the first step since this does not tell us if milk content is sufficiently caloric or nutrient-dense for the babies and whether they are gaining weight. It also doesn't help us know what calorie goals we should have as nursing and exercising moms to ensure that our babies are still getting the calories they need. I really want to study this, folks, but, moving on…

GOT MILK? What to do when you have problems with supply
If you have noticed a drop in supply following returning to workouts or after increasing workout intensity, here are some things to consider:

1. Are you well-hydrated?
You probably aren't. You know that hydration is always rule #1 with me, and until you are urinating a very light yellow color (almost clear), you could always use more fluids. See tips on hydration from last blog post here.

2. Are you sleeping enough?
Of course not. You are a nursing mother! But, are you sleeping enough to make the milk supply that your baby needs and to have enough energy to be the mom you want to be? These are the important questions. No one can tell you how much sleep you need, but most adults need 7-8 hours of sleep a night. Very few of us are getting that, but that's what studies show is healthy. To be honest, during Ironman training, I need 9-10 hours of sleep a night. That's just what my body needs to recover adequately from heavy endurance workouts. Hence, I'm not Iron-training with a newborn. Since my daughter's birth, I can count on one hand the times I have gotten the 7-8 hours recommended for adults even in the form of cumulative sleep in 24 hours. (A lot of that has to do with being a pediatric resident in addition to a mom, but some of it is just motherhood.) What I have found helpful is getting a larger chunk of sleep at night, up to 4-5 hours, and then trying to nap during the day. I don't really get to nap during the day when I am working or when I am off and taking care of Vi by myself because now she really doesn't nap during the day, so this doesn't happen often, but, if your baby and your schedule give you the opportunity to nap or sleep longer, then you take it! I know this sometimes means missing out on your one opportunity to work out that day or your one opportunity to clean up the wreck that is your house, but sometimes sleep is more important, especially if you are noticing a decrease in milk supply.

3. Are you eating enough?
Although nursing mothers are encouraged to eat an additional 300-500 calories per day, it is hard to know for each mother/infant combo how many calories are needed for nursing. Oxytocin, the hormone that helps your body produce milk, also works in digestion, and different women respond differently to this hormone. For some women, nursing may use many calories and make them lose all of their baby weight, and for others, it may make them more efficient at digesting food and getting calories from it, thus more efficient at making milk on less calorie intake. All I can say is that this goes along with what we learned about exercising during pregnancy- you have to listen to your body. In this case, listen to your body, to your baby, and to your milk supply! In general, try to maintain a healthy, varied diet rich in fruits/vegetables, high in fiber (That’s for you so you are not constipated!), and include some omega-3 fats. Remember you should be having liquids throughout the day and frequent snacks with lean protein. I have tried everywhere from 1700 to 2500 calories per day, sometimes with additional calories on harder workout days, and I have to tell you that what gives me the most energy and the best milk supply is eating a snack every 3 hours…which makes sense because it goes along with how frequently I am pumping while away from my baby. When I am with her and nursing her all day, she is my cute little milk monster and eats every 2 hours and I just try frantically to keep up :-P (Disclosure: not every baby eats like Violet does at her age; she is just sleeping a ton at night and has to get in calories when she is awake. Don’t hate me for having a baby that sleeps- I rarely see her. I also don’t anticipate this lasting long!)

On a more superficial note, I often wish my body was smart enough to take the fat that still lingers on my hips, belly, and thighs for Violet's milk, but it's just not; apparently oxytocin makes my body even more efficient at extracting calories from food than endurance training does! I have come to the conclusion that while nursing, you have to decide that yes, you probably could get in excellent shape and be super fit, but, milk supply and your baby's health are more important. If you don't come to that conclusion, then that's also fine, but you might need to supplement more with formula. Ask your pediatrician when you are making that decision.

4. Are you taking time to relieve stress?
If you have been reading this blog for very long, you know how I feel about stress and cortisol. They can help your body overcome amazing things, but when you are trying to lose weight or you are trying to pump milk, they can be real downers. If you are extremely stressed out, your milk production and your letdown reflex are going to suffer. Postpartum anxiety is a real thing, too, just like postpartum depression. If you are having trouble dealing with emotions or dealing with any of this (It's okay to have trouble. Parenting is a tough job, and so is nursing.), then make sure you tell your doctor. I can't tell you how to find balance for yourself any more than the next person can, but when you feel like it is all too much, chances are you need a break, even if it is a short walk without the baby, a light workout, or getting your nails done. Remember that a happy mommy means a happy baby. They pick up on our stress often before anyone else does, including ourselves! And stress does affect you physically, including your milk! Take care of yourself, so you can take care of your baby. It's really ok to do something for yourself regularly; I give you permission.

5. Avoid hormonal birth controls and medicines that can interfere with lactation.
Always ask your doctor if you are not sure if a medication you must take falls under this list.

6. Cluster feeding...
Sometimes babies feed every hour in the evening hours to store up on calories and fill up before going to bed. This does not mean you are losing milk supply, and it does not mean your baby is starving and not getting enough milk. Try not to supplement during this time because your baby is doing a great job of stimulating your body to produce more milk with this frequent feedings.

7. Growth spurts!
Maybe it seems like you are not pumping as much or your baby needs to nurse constantly, and you worry that you are having a drop in supply, but really it could just be that your baby is growing more and increasing his or her nursing frequency or milk intake over a few days to a week in order to take that next step up. It's hard to know for sure until the growth spurt is over, and it's more complicated when you are exercising, but this is something to consider. Major growth spurts generally occur at 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months, and 9 months. But, as a pediatrician, I have to tell you, they are just growing all the time that first year. It is a period of major growth. Nurse as frequently as you can to stimulate milk production and make sure #1-5 are taken of. After that, we can move on to ways to increase supply...

Methods to Increase Milk Supply

1. Mindful pumping
Violet watching Mommy doing her PT 
exercises. Looking at a cute picture like 
this, of course you will pump more milk!
 Make sure when you are pumping that you are giving your body the opportunity to get the most milk out of that time spent on the pump. Work can be stressful. It's important that when you go wherever you are going to pump that you make a mental separation for yourself. Grab a snack and some water, go to your pumping place, take a deep breath, and RELAX. Look at pictures of your baby or have a video of your baby to watch. If you continue to do your desk work while you are pumping, the amount you pump won't be nearly as much as it would be if you were thinking of your baby. Recorded cries from your baby are also helpful because our bodies are physiologically wired to respond to that.

2. Pumping frequency
When away from your baby, try to pump at least every 3 hours. You can get away with every 4 hours, and you should never go longer than 5-6 hours without pumping, but if you are trying to keep up with a baby in a growth spurt, or if you are noticing a drop in milk supply, then aim for every 3 hours. This also goes for night time- sorry folks, but you shouldn't go longer than 5-6 hours without pumping even at night. You get a better pump output and letdown if you pump when you wake up naturally, so try not to set an alarm to pump. I usually wake naturally at 3-4am, so that is when I pump and sometimes even workout because it gets trickier to fit that in later in the day.

3. Pumping technique and hand expression
Try changing the setting on your pump to increased frequency when your letdown slows on the pump and then go back to the slower frequency once letdown happens again; try to stay on the pump for a full 30 minutes if you have the time to ensure that you get multiple letdowns during the pump. (I have a really slow letdown at times, so I always get more if I stay on for 35-40 minutes, but I only do this during my morning pump when I have gone 5 hours between feeds/pumps.) Hand expression is also clinically proven to increase milk supply. You can hand express while pumping, and this has been shown to increase the amount you pump. However, it also helps get your baby to feed better on the breast for babies that are slow feeders. Go here for instructions on how to do breast compression while baby is feeding: There are also YouTube videos out there on this stuff, and your lactation consultant can also work with you to teach you how if you are having trouble.

4. Let your baby do the work
Pump on your way home and have whoever is watching your baby not feed in the hour or so before you are coming home, so that when you get home, your baby will be very hungry and stimulate milk production. If that sounds mean to you, just remember that your breasts should make milk while your baby is nursing. Another thing to try is a whole weekend or 2-3 days of high intensity nursing. Nothing stimulates increased milk supply like your baby! Spend a couple days with your baby and nurse for every feed (no bottles), so your baby can ramp up your supply. This works. Whenever I have a weekend off to be with Violet, I go back to work on Monday, and my boobs ache all day and I always look forward to when I get to pump because I am making so much extra milk.

5. Galactogogues
Galactogogues are substances that have been shown to increase milk supply in some studies. There are natural ones- almonds, oatmeal, fenugreek, milk thistle, etc. There is mostly anecdotal evidence to support these. Fenugreek has the most evidence, but anecdotally, it doesn't work for everyone. There are medicines that can be prescribed by your doctor, such as metoclopamide (available in U.S.) and domperidone (Canada only) that may also help. These work by blocking dopamine receptors and increasing prolactin levels. It doesn't hurt to ask your doctor if you have tried everything else.

Good luck, ladies!

On deck:
-Part 3
-pelvic floor syndrome and athletes
-running stroller safety


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Brewer et al. Postpartum changes in maternal weight and body fat depots in lactating vs nonlactating women. Am J Clin Nutr 1989 Feb;49(2):259-65.

Noble et al. Oxytocin in the Ventromedial Hypothalamic Nucleus Reduces Feeding and Acutely Increases Energy Expenditure. J Anim Sci. 2000 Oct;78(10):2696-705.

Laatikainen TJ. Corticotropin-releasing hormone and opioid peptides in reproduction and stress. Ann Med. 1991;23(5):489-96.

Sadurskis et al. Energy metabolism, body composition and milk production in healthy Swedish women during lactation. Am J Clin Nutr 1988 Jul;48(1): 44-9.

Sohlström A, Forsum E. Changes in adipose tissue volume and distribution during reproduction in Swedish women as assessed by magnetic resonance imaging. Am J Clin Nutr 1995 (2):287-95.

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