Preparing to Breastfeed after Breast and Nipple Surgeries

Congratulations on your decision to breastfeed your baby!  That is a tremendous gift that you will give that will convey lifelong benefits.

You will most certainly have the ability to breastfeed, although there is no way to know if you will have a full milk supply before your baby is born.  Most mothers who have had breast and nipple surgeries *do* produce a significant quantity of milk, but not all have a full milk supply.  Although ducts may have been severed during the surgery, over time many of those ducts grow back together.  This happens at an accelerated pace under the influence of pregnancy hormones, so this pregnancy and any other previous pregnancies (after the surgery) may have prompted least some of your ducts to grown back (recanalize).  It generally takes about five years for nerves to grow back to significant or full functionality.

There is no way to know how much milk you will be able to produce and express until your milk comes in around the fourth day after birth.  The amount of milk you will have then will be dependent on the number of connected ducts and state of the nerves that affect lactation.  The glands connected to the ducts that were severed during the surgery will produce milk initially, but because the milk cannot get out, they will gradually stop making milk and will atrophy over the first two weeks.  You will probably experience the some engorgement as a result, in addition to the normal fullness when the milk comes in around the fourth day.  After the engorgement stage is over and the glands have atrophied, your milk production will be dependent on the glands connected to the intact ducts.  If they cannot produce enough milk initially, there is much that can be done produce more.

The amount of sensitivity in your nipple demonstrates how well the nerves that affect lactation have healed.  During the healing process, they may become more sensitive than normal, but over time, the sensitivity will most likely return to the way they were before the surgery. These nerves affect how milk is released from the breast (let-down).  When they are not functioning properly, it can be harder to express the milk.  If you do not have full sensitivity, it may be helpful to know that there are several ways to augment milk release -- herbs, breast compressions, and psychological conditioning.  For now it may be helpful to know about the most effective of them, breast compression. There is also some general information about milk ejection on the Kellymom.com website. 

Even if you don't have enough milk, you can have a very fulfilling breastfeeding experience, and there are many ways to increase your milk production.  Remember, too, that breastfeeding is more than just producing food for your baby. 

Before your baby is born, it's important to learn as much as you can about breastfeeding after breast reduction surgery.  The BFAR book is a good place to start: "Defining Your Own Success: Breastfeeding after Breast Reduction Surgery."  The book contains information on every aspect of breastfeeding after breast reduction surgery, including specific information on supplementing so as to maximize the milk supply and ways to increase the milk production.  It may be very helpful to read this book now so that you have a thorough understanding of all the issues and strategies that will maximize your milk production.  There is also a chapter that will be particularly helpful that is just about what you can do before the baby is born.  You can purchase the book from the BFAR website or order it through any bookseller. 

Some of the information about supplementation and increasing milk production has changed, though.  Most of the updated information is on our sister site, lowmilksupply.org.  There is also a new book entitled "Making More Milk: A Nursing Mother's Guide to Milk Supply" coming out in a few months all about low milk production, including the latest information in supplementation and increasing milk production. 

It will also be helpful to connect with other moms who have had reduction surgery -- you can do this through the BFAR forums -- a fantastic source of information and support. 

Another important thing you can also do now is to find a good private-practice lactation consultant in your area so that you will know who to call if things don't go well.    One place to find one is the BFAR lactation consultant referral list. If there is no one near you there, try the ILCA LC referral list.

But the best thing you can do to maximize your breastfeeding experience is one simple thing (that isn't always so simple):  remove as much milk as possible in the first two weeks.  This is because the amount of milk the breasts are programmed to make is determined in the first two to three weeks.   The more milk that is removed during that time, the more milk-making capacity your breasts will have.  The way this happens is that milk removal establishes as hormone receptors in the breasts.  The more milk that is removed, the more hormone receptors that are established.  Hormone receptors are necessary to maximize the body's ability to use the hormones that are produced.  The more receptors you have, the more effective the hormones will be to make and release milk.  Even if you can't pump much volume, just *asking* your body to remove milk by pumping and nursing establishes receptors.  So your primary goal in the first three weeks is to do everything you can to remove as much milk as possible.  Obviously, the best way to do this is through breastfeeding, but some pumping **with a hospital grade pump** may also be helpful. 

In order to get breastfeeding off to the best start possible, it will help to latch your baby as soon after birth as possible, preferably in the first hour.  Most babies are sleepy after the excitement of birth wears off, often taking a long nap and not having a whole lot of interest in nursing the first day.  However, keep in mind that we are trying to maximize your milk production, so do your best to get your baby to nurse as often as possible when he or she is awake. 

If you are having difficulty getting a painless latch, ask the nurses to bring in a lactation consultant to help.   It should never actually hurt, even though you might feel mild tenderness at first.  Please let me know if you find that you can't get a comfortable latch no matter what you try.  I may have some ideas to help.

At the end of the first day or as soon as you are ready, ask the nurses to bring you an electric pump explaining that you need pump after feedings to maximize your milk production.  Pumping should continue for at least the first two weeks and then until you are sure your baby is getting enough milk .  There is no need to purchase a pump now -- in fact the pumps that are sold in stores are not designed for the maximum milk removal efficiency that you'll need in the early weeks.  Those pumps are designed for moms who have established milk supplies and are going to be separated from their babies during two to four feedings a day, such as returning to work.  If you need a pump in the early weeks, a rental grade (hospital grade) pump will be the best by far. 

One thing to keep in mind is that the amount of milk you can express is not at all reflective of how much milk you have, especially in the first week.  A baby can usually withdraw milk much more effectively.  Also, there isn't much quantity until the end of the week, so the amounts you can pump won't be much anyway.  Do be sure to give your baby any colostrum that you pump.  If it is just drops, wipe it from the bottle with your clean finger and let him or her suck on your finger.  You can also use a spoon or a cup.  Every drop of colostrum is chock-full of precious immunities and intestinal protective factors that will make a huge difference for his health. 

As I wrote in my book, it is still true that there is no need to begin supplementation until you know *for sure* that your baby is not getting enough milk, and most babies don't need supplementation until the third day, although there ARE some who do need small amounts by the end of the second day.

There are two ways to know for sure if supplementation is necessary:  diaper output and weight gain (some of this you know from my book, but I'll just go over it all so it is fresh in your mind). 

From the very beginning, keep a record of your baby's diaper output (the nurses will do this for you in the hospital, but if you change diapers, too, make sure that diaper changes are recorded on the hospital record).   Once home, keep track on a chart (any kind of chart will do). This will tell you how much milk your baby is getting.  Wet diapers should feel as heavy as two tablespoons of fluid if your baby is under eight pounds and three if over eight pounds.  It may be helpful to put this amount of water in a dry diaper before your baby is born to see what it feels like.  In the first twenty-four hours, there should be at least one wet and one stool diaper.  In the second twenty-four hours, there should be at least two wet and two stool diapers.  In the third twenty-four hours, there should be at least three wet and three stool diapers.  At this point, you should begin feeling your milk coming in.  You may feel fuller and sometimes it's a bit more difficult to get baby to latch.  In the fourth twenty-four hours, there should be at least four wet and three stool diapers.  That "quota" will continue throughout the first six weeks.  After that point, stools will slow down in quantity, but will be larger each time, and weight gain will be the more reliable way to know if your baby is getting enough.

Your baby's weight should be monitored closely from the very beginning.  It is normal for babies to lose weight in the first few days.  It isn't true "weight loss" because those first stools expel all the waste matter that had been accumulating in the colon before birth.  After your milk comes in on the third or fourth day, your baby should begin regaining weight at the rate of at least one ounce a day, which should continue for the first four months.  Weight readings can be read inaccurately, though, if comparing weights between two scales because scales can each be calibrated differently.  For this reason, it is important to have your baby weighed on the same scale each time.  At first, this may be the same scale in the hospital nursery.  When you go home, it may be on the same scale in your doctor's office.  It is important to get that first reading on the scale you will usually be using so that you aren't comparing weights on different scales.

If your baby is not having enough diaper output or weight gain, then supplementation is necessary.  Don't hesitate to supplement if your baby needs it -- your baby must have adequate calories to feed well.  Adequate fluids also help flush out bilirubin to avoid jaundice, which can make babies too sleepy to feed well.  Supplementation need not be a "slippery slope."  It's just important to give the supplementation in a way that interferes as little as possible with breastfeeding, and for you to continue to remove as much milk as possible while supplementation is given.

If you do have to supplement, you might consider finger-feeding to begin with. If you want to use bottle, though, it won't necessarily interfere with breastfeeding.  Contrary to what was written in BFAR book, we have now learned that bottles *can* be used in ways that are supportive of breastfeeding.  There is an excerpt from my new book that explains a new method of supplementing with bottles that many mothers are finding to be very helpful for breastfeeding.  Here are links to pages with more information on ways to use bottles that maximize breastfeeding:

http://www.bfar.org/nipples.php
http://www.bfar.org/bottle.php
http://www.kellymom.com/bf/pumping/alternative-feeding.html

If you think you might want to use a bottle if supplementation is necessary, you might consider having a bottle with a good nipple on hand.  Gerber, Evenflo, and Playtex all now have wide-based nipples that are MUCH better than the ones provided by the hospital, which are donated by formula companies.

If supplementation *is* necessary, try not to worry and keep in mind that there is quite a bit that can be done to increase milk production, including new ways that are not in the BFAR book.  Try to take things one day at a time and reach out to other BFAR mothers through the BFAR forums or contact us if you need to.