Thursday, March 26, 2015

Nurse Charity shares her wisdom about breast pumps

What Breast Pump Should I get?

This is a common question here at the office, it used to be that only moms with sick babies, or moms going back to work even thought about a breast pump, but now they are so part of our breastfeeding culture, even Moms who are only looking to offer an occasional convenience bottle of expressed milk are asking about what pump to buy.  Here is a short little run down.

Pro tip:  If you have a non-latching baby, a preemie baby, or a baby who is not gaining appropriate weight you must hand express well, or have a hospital grade pump.  I know the sellers and manufacturers say their home pump product is as good as the hospital grade pumps.  They are not.  Rent a pump!   

There are a lot of pumps out there- I mean a lot, a lot, A LOT!  Everyone is trying to get in on the breast pump market, and new ones pop up all the time. This is a post about the tried and true.  No pump out there is perfect, current technology focuses on suction as a way to move milk- and misses the all important complementary action of compressions!  Here are the pumps I recommend- they all have flaws- I will list my qibbles along with the recommendation.  If it made the list- it is a good product, but there is always room for improvment.

Sometimes the best pump is NONE!

If you are pumping occasionally to offer a bottle every once in a while- really, any method of milk expression will work for you.  Hand expression, once learned is one of the very best ways to move milk quickly.  It is cheap, and really the only cost is the time it takes to learn.  Babies are portable, and so are breasts, so don’t feel pressure to introduce a bottle unless you really want to.  
It is legal in California to nurse your baby *anywhere* you have the right to be.

Pro tip: All moms should know how to hand express.  If the power goes out (like for an earthquake or other disaster) knowing how to hand express is crucial.  learn here:

Pumps for the Working Mom

Double electric (meaning it pumps both sides at once, using electricity to drive the motor) purchased home use pumps are designed for moms with an established milk supply (have been nursing with good results longer than 6 weeks)  that are going to be away from their babies for 6-10 hours.  The two products easily available in the Bay Area are the Pump In Style and the Free Style from Medela, and the Purely Yours from Ameda.  

Medela-  The Pump In Style Advanced (PISA) gives moms a great double sided pump with automatic cycling (mimics the initial fast suck of a baby, then slows after a few minutes with greater suction)- almost as good as the hospital grade product.  Yay!  Drawback?  Most expensive, probably overpriced, is built into the bag it comes with, so you are stuck with whatever Medela thinks is trendy that year, usually basic black.  To try to address this issue they made another smaller, more portable pump they claim is as good as the PISA- The Freestyle.  If only the claims were true!   Most moms in our practice get significantly less milk with the Freestyle.  if you want a medela product, go with the PISA.   I am consistently disappointed in Medela.  The Pump in Style Advanced and Freestyle  continue to be open system pumps (meaning the milk can back up into the pump), and because of the risk of infection is not recognized for shared use.  Medela’s hospital grade pumps- The Symphony and the Lactina are both closed system (milk cannot get into the pump)- so they have the technology to make a better pump- and instead make each mom worry about cross contamination, and mandate (under void of warranty threats) that each mom buy their own.  In addition, they have yet to make all the tubing (the part that gets plugged into the pump) the same so if you have a kit for the hospital grade pump, it does not fit your home pump.  Boo Medela!  way to milk Moms for every penny.  A guy on youtube has a tutorial on how he takes pumps apart and cleans them.  Worth a look if you are borrowing an open system pump.  

Ameda-  The Ameda product is called Purely Yours,  it is a great home pump, with a closed system, the pump parts are interchangeable with the hospital grade offering (Elite or Platinum), a lot of insurance companies are covering this choice, and you can house it in your own bag.    Yay!  But it lacks the automatic cycling.  You can of course set the speed to fast, and the suction to light at the beginning and change it over with the let down to slower, with more suction, but most tired moms would prefer a single button like the Medela product.   In addition, about every 100 pumps, I get one with a bad motor (suction is poor, and the motor is LOUD!).  It needs to be returned as a dud, what new mom has the time for that?  

Hygeia- There is a less well known company, Hygeia, that also has home pumps and hospital grade pumps.  They are awesome!  (and the only pump company in compliance  with WHO marketing standards).  Great product if you can get it.  hard to find in regular shops, easy to order online.  Better motor than the Purely Yours, but no automatic cycle on the suction.   

There are some new pumps out there that don’t have enough of a track record yet for me to have an opinion either way (Like the Freemie pump) and a lot of pumps that are better to just avoid (anything made by a toy company, like First Years or the new Lansinoh pump, the old one was a purple version of the Purely Yours, the new one is not as good).

Pro-tip:  If you pump in the hospital- take the kit with you when you leave.  If you buy the home version of the pump you used in the hospital- then you will have two sets of flanges and extra parts.

Hand Pumps
There are other pumps out there, hand pumps and single electric pumps, of the two I prefer the hand pump- no electricity needed, and the designs are pretty mom friendly/easy to work.    The Ameda hand pump, and the Avent hand pump are the best manual single pumps. 

Single Electric Pump- Just skip it.

The single electric pumps from any brand are really just toys, if you want to have just an occasional bottle of expressed milk for a special occasion-  I recommend a hand pump, or learning to hand express.  Hand expression had be just as effective as an electric pump, once you know how to do it.  If you like the electric pumps- just buy the Purely Yours, or the PISA.   

            How to Pump

Ok I have the pump, I know how to hand express- now what do I do?

Wait until nursing is going *well* for 4-6 weeks.  We don’t recommend pumping for non medical need until after the first 4-6 weeks.  This lets you get the hang of nursing without adding any extra work.   Mostly the problem I see for Moms who start pumping early is oversupply.  Trust me, too much milk can be as much of a burden as not enough- so unless you need to, best to wait until the 1 month to six week mark.  

If you pump or hand express at the beginning of the day, you can collect the most milk.  if you are expressing to have milk for a sitter, or some stash for when you go back to work- the time that usually gives you the best yield is at the beginning of the day.  In general, because moms are trying to get some well earned rest, babies nurse a little less at night and as a result there is a little more milk in milk storage.  Although the definition of morning varies by family- I am not suggesting pumping at 4 or 5 am, but when you are actually awake, and ready to greet the day- sometime between 7 and 11.   

Pump directly after your baby feeds.  Baby nurses until milk drunk- then express/pump, both sides until the breast is very soft.  The time it takes for this varies- could be 10 minutes, could be 40 minutes- depends on how big your milk supply is, and how much milk is in milk storage.

Practice! Letting down to your baby is easy, letting down to a pump takes some practice.  Lots of moms pump the first time and get dribs and drabs- this does not mean you do not have milk!  It just means your body has not realized that the suction of the pump is an appropriate stimulus to remove milk. My Mom had a friend in the 70’s who pumped for her preemie baby- the pumps back then were LOUD.  When she got home, she found out that her body let milk down when her refrigerator  “cycled” making a loud humm.  Her body had learned to let down for the SOUND of the pump- not the suction.  Expect to pump-3-6x before the milk starts to really flow.

Tips for Comfortable Pumping

Lubricate the inside of the flanges.  Food grade oil, olive or coconut works well.  It prevents your damp skin from getting friction damage rubbing over the plastic.  

Set your suction at the highest part of comfortable, not the lowest part of tolerable.  Most women pick a setting of pumping that is a little bit uncomfortable, thinking the stronger suction will bring more milk.  Unfortunately, what facilitates letdown is oxytocin.  Pain, even the pinchy, tuggy pain of the pump can interfere with oxytocin circulation, and suppresses let down.  Make sure your pump is in the comfortable range.  To do that, I usually turn it up until it is barely pinchy- then back down to the comfortable range.   Once you know your comfort range- keep it there.    Even at the lowest settings, the pump will still be effective (that is why you got the good one- and skipped the crap).  

Do breast compressions while pumping.  Lactation consultants have recommended this for years- at least 20.  Now we have the studies to back up the recommendation.  Jane Morton calls it hands on pumping (ooh fancy name)  but really, all we are asking you to do is do a deep breast squeeze (deep- meaning you can feel the structure of the breast under your fingers when you compress) while you pump.  Studies show you can move up to 30% MORE milk if you do compressions while pumping.

If you use a hands free bra- make sure it FITS! A hands free pumping bra that pushes the flanges too deeply into the breast tissue can impede the flow of milk, and reduce your yield.  The flanges should seal, but not dig too deeply in any one spot.  

Several quick pumps are more effective long term than a few long pumps.  The breast is not a container- it is a modified sweat gland- so pumping more frequently helps keep baseline prolactin levels high, and moves more milk over time.  I know it is tempting to put off pumping, and pump a looong time (20-30 minutes), and see the full bottles, but trust me on this one.  If you have limited time- several short pumps (10-15) are better than 1-2 marathon pumps.

The longer you are away from your baby- the more pumping session you need to get in.  In general- if you are going to be away from your baby for 6 hours, you need three pumps, for 8 hours you need at least four pumps, for 10 hours, 5 pumps.  A pump does not move milk as well as a baby- so an extra pump helps keep it even.  

Milk storage guidelines are 5/5/5  5 Hours at room temperature, 5 days in the refrigerator, 5 months in the freezer.  You will see other recommendations- I like 5/5/5 because it is easy to remember.   

Happy Milk Expression!

Hint Mama adds the following tip: It's also worth noting that Obamacare heralded in free pumps for moms, so people no longer have to buy pumps. Here are the details:

Friday, March 20, 2015


Please see the updated post October 2017
This week I am going to talk about eczema.

Some babies have buttery soft skin. Others are not so lucky. The very dry skin is prone to all sorts of rashes. This is one of those topics that we routinely get calls about year round. It doesn’t have a season. Understanding some basic facts about the skin can help you understand what is going on and how to deal with it.

The term eczema is broadly applied to a range of persistent skin conditions.
Eczema actually comes from the Greek word for “eruption”. You may also hear it referred to as Atopic Dermatitis. The top layer of the skin is called the epidermis and the top layer of the epidermis is called the stratum corneum (SC). The SC is incredibly thin but it is the main barrier of the skin. It keeps chemicals that come in contact with the skin from being absorbed into the body, and it keeps fluid inside the skin from leaching out. The SC contains 3 types of lipids that have different chemical compositions and functions; ceramides, cholesterol and free fatty acids. But it gets even more complicated. There are nine different types of ceramides in the SC, conveniently named ceramide 1 through ceramide 9, and they account for 40-50% of the lipids in this outermost layer. Scientists are doing a lot of research on the important function that ceramides play. What they are now discovering is that people with eczema have significantly fewer ceramides in the SC than folks with healthy skin. (Don’t worry there won’t be a test on this.)

The obvious focus is to try to rebalance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing! There are some very good products that can make a big difference. Dr Lawrence Cheung is my go to dermatologist who sees a lot of our patients. He lists the following products as some of his favorites:

Aveeno Eczema Therapy
Cetaphil Restoraderm
Cerave Hydrating Cleanser and Moisturizing Cream

Eucerin and Vaniply are a few other good brands. Read the labels and make sure that ceramides are on the list of ingredients.

If you like home remedies, my sister-in-law Barbara swears by coconut oil mixed with a bit of tea tree oil.

Well lubricated skin does not get as itchy and doesn’t break down as easily. Grease up your kid at least twice a day. There is no down side. It is really important to break that itch cycle. Aside from causing misery, scratching can tear the skin, and an infection can occur.

There does seem to be a hereditary component to this condition so it is pretty common for eczema to run in families. My patients with this diagnosis generally have fairly dry skin with rough patches. These kids (and adults) seem to be much more sensitive to various foods and other environmental factors.. Something that is making the skin reactive is referred to as a trigger. Triggers can range from changes in temperature, a new detergent, teething or a new food. Acidic foods seem to be big culprit for some kids.
Every year when it is “easy peel” tangerine season, I start getting loads of calls about patients whose eczema is flaring up like crazy. Other kids seem to react to dairy. My daughter Lauren got horrible eczema when she first switched to cows milk. I stopped it for a while; when we retried it several months later she was fine with it. Sometimes you just need to do some trial and error experiments.

When food sensitivity is to blame you will often see chappy cheeks and
a red ring around the anal area.

People used to recommend infrequent bathing, but it turns out that this is a myth.
If your child likes their bath, you can give one as often as you like. Baths are fine, but sitting in soapy water for extended periods is not such a good idea. Let them do their “fun in the tub” session for most of the bath first and then do the actual washing and rinsing with gentle soap and shampoo right before getting out. Bubble baths and harsh soaps are pretty high on my list of suspects when I am sleuthing around for the cause of a rash.

Some folks find that adding a splash of apple cider vinegar to the bath water (about ¼-½ cup for a big tub) is soothing and may even prevent some rashes. If the eczema is severe, believe it or not a bleach bath is often recommended by many dermatologists.

Here are important steps for giving a bleach bath:

1.      Use regular strength – 6 percent – bleach for the bath. Do not use concentrated bleach.
2.      Use a measuring cup or measuring spoon to add the bleach to the bath. Adding too much bleach to the bath can irritate your children’s skin. Adding too little bleach may not help.
3.      Measure the amount of bleach before adding it to the bath water. For a full bathtub of water, use a half cup of bleach. For a half-full tub of water, add a quarter cup of bleach. For a baby or toddler bathtub, add one teaspoon of bleach per gallon of water.
4.      Never apply bleach directly to your child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before your child enters the tub.
5.      Talk with your dermatologist about how long your child should soak in the tub. Most dermatologists recommend a five- to 10-minute soak.

All baths should be followed up immediately with some lotion!!!

Dr Jessica advocates the “greased pajama” method. Put the jammies on right after applying the moisturizer. The pajamas will be a little greasy. As long as they stay clean otherwise, wear those for several nights in a row.

As I already mentioned, we want to minimize itching. If your child is doing a lot of scratching we may end up recommending an antihistamine.  Zyrtec (cetirizine) and Benadryl (diphenhydramine) are the two main brands that we tend to use.  Benadryl is shorter acting. Most of the time it makes the kids sleepy, but once in a while it has the opposite effect (not something you want to find out at night.)  Zyrtec is longer lasting and doesn’t tend to cause either the sleepies or the jitters.
Although the label will warn you to check with your MD if you child is under 2 years, Dr. Kaplan has no hesitation giving the Zyrtec as young as 6 months if necessary. It comes in a liquid form. She would start with ½ teaspoon at bedtime.

Hydrocortisone creams or ointments can be used to spot treat especially itchy areas. I would start with the weaker over the counter strength. If that isn’t helping, it would be a good idea to have a doctor take a look. We have options of different prescription strength ointments, creams and oils that we might try. Most of the time simple eczema can be handled by your pediatricians office. Once in a while complicated cases that are not responding to treatment may end up at the dermatologist. Make sure your kids nails are kept short. Infants can have little mittens on their hands at night if they are doing a lot of scratching.

Friday, March 13, 2015

Pink Eye

We have been seeing lots of pink eye these past couple of weeks. Medical lingo for pink eye is conjunctivitis, which simply refers to an inflammation of the conjunctiva. The conjunctiva is the thin clear tissue that lies over the white part of the eye and lines the inside of the eyelid.

When small blood vessels in the conjunctiva become inflamed, they're more visible. This is what causes the whites of your eyes to appear reddish or pink.  Symptoms might include:

·         Redness in the white of the eye or inner eyelid
·         Increased amount of tears
·         Thick yellow discharge that crusts over the eyelashes, especially after sleep
·         Green or white discharge from the eye
·         Itchy eyes
·         Burning eyes
·         Blurred vision
·         Increased sensitivity to light

Sometimes the white part of the eyeball (also known as the sclera) will look just fine. If you suspect conjunctivitis, check to see if the inner lining of the eye looks redder than normal. My favorite way to check is to put a finger on the upper part of the cheek and gently pull down. This will allow you to assess the color inside that lower lid. Check both eyes.

Pink eye has a number of different causes, including:

Allergies (dust or pollen)
Irritants like smoke, pollution, or a strong chemical odor ( some heavily chlorinated pools can do induce this)

The conjunctivitis from a virus or bacteria can be easily spread from one person to another.

Bacterial conjunctivitis is usually caused by Staph or Strep. It is treated with antibiotic eye drops. Dr Schwanke also likes to add a dab of topical antibiotic ointment to the inside of the nostrils several times a day. Hands going from snotty nose up to eye rubbing are a common way for pinkeye to spread. He often prescribes a medication called Mupirocin. Over the counter Neosporin is another option.

It can clear up on it’s own, but might take quite a bit longer if untreated. Most schools and daycares will not want your child to attend if they have an obvious case of conjunctivitis, so some parents opt to start treatment sooner, so that they can get back to work.

Although often the eye drops will come with directions to give 4 times a day, many of our patients have a hard time managing that. 4 times/day is optimal, but 3 times/day is usually adequate. Some of the newer antibiotic drops don’t need to be given as frequently, but may not be covered by your insurance. The directions will often come with a range of time that you need to do the treatment; for example 3-7 days. I suggest that you continue to treat for a full 2 days after the eyes have cleared up. Don’t partially treat or it is likely to come back. 3-5 days is usually standard. Your child is no longer considered contagious after they have completed a full day of the drops.

If you don’t notice an improvement after 48 hours, your child needs to be reevaluated.

Getting those drops in can be somewhat of an art. I have some parents who claim that it is easier to give a bath to an angry cat. It may be a 2 person job. If your child is very uncooperative you may need to wrap them in a blanket so that they don’t have their arms to flail around. Gently pull down the lid. Even if they are clenching their eyes tightly shut, you should be able to find a little pocket in which to put the drops. Try not to touch the dropper tip to the eye. This is harder than you think, for that reason….

Please don’t share drops between family members!

For older kids, a little preparation before you go at them with the eye drops can go a long way. Let them do some playing. Have them give “drops” to 2 different dolls or stuffed animals. Make one cooperative. Give them lots of praise for being brave. Make the other one kick a fit. You get the idea.

When I see those goopy eyes show up, fully half of my patients have something else going on. Most of the time the pink eye is coming along with an ear infection and/or sinus infection. Those kids will likely end up being treated with oral antibiotics.

Because of this, I will usually suggest that they get seen in the office. If your child is over 5, is acting perfectly well, and it is difficult to get into the office, exceptions are sometimes made and drops can be phoned it, but it is usually better to have them checked.

Viral: Many cases of pinkeye come from the same viruses that cause a common cold. Just as a cold must run its course, so must this form of pinkeye, which usually lasts from four to seven days. Viral conjunctivitis can be highly contagious. Avoid contact with others and wash your hands frequently.

Both bacterial and viral can start in one eye and then spread to the other. If there is a lot of green and yellow pus, it is more likely (but not absolute) that it is bacterial. To avoid spreading the infection, swap out pillow cases, and wash clothes or towels that might have been in contact with the goopy eyes.

Allergic: If Allergies are the culprit, both eyes will likely be affected. These eyes are usually watery and itchy. There is an OTC drop called Zaditor that I really like for kids older than 3. Pataday is another allergy eye drop option, but it is a prescription. Allergy eye drops can be used on an as needed basis. Often it is worth seeing if a few drops makes everything better. If so, it is allergic and you don’t need to be stuck doing a several day course of antibiotic drops.

If your baby is under  4 months, gooey eyes may be from a blocked tear duct:

If you happen to have breast milk, feel free to use it for any type of pink eye. You never know; I have seen it help.

What makes me worried?
If the area around the eye looks very pink or red and swollen, that could be something called periorbital cellulitis and it can be quite serious if untreated. This would generally come with a fever and a child who looks ill.