How to combine breastfeeding with business travel

Breastfeeding has many advantages. One of them is not the ability to mix well with business travel. I have been able to combine business travel with breastfeeding, and I thought I would share some tips.

Building up a frozen stash before your trip

If you want to exclusively feed your infant your own milk, you need to start planning your trip well ahead of time. If you don’t have a large supply already in your freezer, you need to build up your supply so that you can freeze the extra milk that you produce. I would start at least one week ahead of time, plus one week for each 24-hour period that you will be away, and if you can an extra week to allow you to reduce your supply again before you leave. I counted on producing about 5 ounces (150 ml) extra per day once I got going, and if I saved this amount every day for 1 week it would be enough to feed an infant aged 4-6 months for 1 day. Older infants drink less and you can probably get by with less.

You can store milk in the plastic bags that are provided by Medela or other breast pump manufacturers, but they can be expensive. Other possibilities include glass jars, plastic jars like they use in hospitals for various biological samples, or bags made of PC, PE or PP (see a rather technical article here about the pluses and minuses). You probably want to have a little section in your freezer for all the milk.

When I started, I thought initially that I would just pump what I had left over at the end of the day. Unfortunately, it seemed that I didn’t have anything left by then. So I changed tactics and pumped in the morning after the first feed, on the side that was fullest after the feed. This worked out fine, and in a few days my supply adjusted.

On your trip:

  • Try to plan your trip so that you will be able to express milk regularly. How much you need to express depends on your current supply and how uncomfortable you normally feel if you express less regularly. Expect to have to express milk at the start and end of the day in your hotel room, and probably at least twice during the day. Phone ahead and ask at your location about facilities for expressing milk.
  • Take your breast pump with you everywhere you go, including into the plane as carry-on baggage. Travel plans may change (e.g. I have been stuck on a plane for 8 hours extra due to poor weather) and you don’t want to be caught without it.
  • You might want to pack a large scarf so that – if necessary – you can pump on the move (e.g. on a plane or in a train).
  • Try to arrange access to a refrigerator or freezer before your trip, e.g. at the hotel and wherever you will be going. Frozen milk will stay frozen if you pack it together in something that insulates (e.g. your clothes) and is checked into the hold of the plane. If you can take your expressed milk back with you, it will mean that you are prepared for your next trip 🙂
  • It’s a good idea to have your battery pack loaded in addition to the power cable, especially if you are not sure where you will be able to pump or are going to a location with a different voltage.
  • Take plenty of storage containers or bags, extra breast flanges, and batteries with you.
  • You might find that you have difficulties with the “let down” response after you have been away for a bit, or that you get clogged ducts while away. Make sure you are giving yourself plenty of time to express milk. Encourage a good “let down” by looking at photos of your baby, thinking about what it is like to nurse, etc. I also find that breathing out while imagining the milk flowing out is a good way to get it to flow well. Express milk after a warm shower, and encourage the water onto your breasts during the shower to help clear blockages.
  • Don’t forget your breast pump!

 

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Reply to commentary on ELF study

There was a study published a little while ago showing that early, limited formula feeding (ELF) was associated with increased breastfeeding rates in older infants, and not by a little bit. Although it was small, I was impressed with the results, and they changed my thinking about the use of formula. Using formula vs. breastfeeding is often portrayed as a black or white issue. This is partly due to the research, which often only compares exclusive breastfeeding with exclusive formula feeding, despite the fact that many women use both methods at the same time. Perhaps by not polarizing the issue, we can do a better job of helping women to breastfeed for longer?

This is not the view that is supported by a writer from Best for Babes. She wrote a post criticising the study, but it is clear that she is a proponent of 100% exclusive breastfeeding and does not have a background in science or clinical research. Just because a study contradicts what you expect, doesn’t make it flawed. I was so annoyed by her responses, that I wrote my own counter-response. Her statements are in bold.

Prior research shows that use of formula without medical indication strongly undermines breastfeeding.

The researchers hypothesize “adding the early use of limited volumes of formula in addition to breastfeeding before the onset of mature milk production would have high potential for reducing breastfeeding discontinuation for some mothers by ameliorating milk supply concern”. I understood that this approach has not been tested before in an intervention study. The fact that the study results, what answer a very specific research question, contradict general advice about breastfeeding is not a flaw, that’s just what the results show.

The wrong criteria for newborn weight loss

The researchers probably were not allowed to use a clinically relevant loss of weight without providing the standard treatment of care as it would have been deemed unethical. Anyone can give a healthy infant formula, but an infant that has lost more than 10% of its weight should not be included in a research study unless it is first treated for its weight loss.

Why try this? We already know what works.

We still need more research. The BFHI is a hospital-based initiative to improve breastfeeding rates, but the individual parts of it need to be tested. If the results from this research study are repeated in a larger study, the Early Limited Formula (ELF) approach could conceivably be considered as part of the BFHI.

Sample size too small, no controlling for other factors

This was a pilot study, hence small study numbers. Controlling for other factors is relevant for observational research, but this was interventional.

One author has financial ties to formula companies

This is a potential conflict of interest, however often formula companies choose to do research with people who have experience in the field. It does not necessarily mean that the research is flawed.

Milk came in late for one quarter of the mothers.

This is exactly why ELF may work: by using formula to help infants who are extremely hungry due to late arrival of milk, they may breastfeed better, explaining why ELF is likely to be successful.

Using formula to supplement instead of human milk.

Formula is a good alternative to expressed breast milk, especially if women have a low supply or their milk comes in late. Expecting women to express breastmilk in the early postpartum period when they have a low supply or their milk has not come in seems unrealistic.

Undermining recent progress.
This study shows that breastfeeding rates improves if women who had difficulties feeding their newborns were encouraged to use infant formula for a limited time. Improving breastfeeding rates sounds like progress to me.

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Effect of frequency of breastfeeding on milk production

Breastfeeding my daughter is now well established at 3 1/2 weeks and I am confident we can continue to reach the goal of 6 months exclusive breastfeeding.

I have not had any issues breastfeeding at all (after the nipple trauma cleared up two weeks ago!). The only problem I had, was the recommendation from a number of sources than I should be feeding every two hours or risk reducing my milk supply. This was a little stressful for me because my baby could not be woken up enough to feed properly every two hours. It worked like this when I tried: two hours after a feeding, I would try to rouse her for an hour, she would suckle half-heartedly for a few minutes then drop off to sleep again. I tried all the classic tricks like tickling her feet, changing her nappy, and even washing her face with a cold wash cloth (she screamed like I was trying to kill her for a minute, then went back to sleep). It was a pointless exercise. She was impossible to feed every two hours. I was concerned about my milk supply, however I was more concerned about the stress I was putting her under waking her and trying to get her to feed more frequently than she seemed to want. Also, after the first day she regained her birth weight and was almost one kilo above her birth weight at the 2-week visit. She clearly was getting enough milk! I resented the standard advice I was given that obviously wasn’t appropriate for my baby.

According to my nutrition textbook (Nutrition Through the Life Cycle, 4th edition, by Judith E Brown), the amount of milk removed over a 24-hour period determines milk production rather than the frequency of feedings. So perhaps this advice that women should breastfeed their infants frequently isn’t really based on scientific evidence.

I looked up some research that looked at milk synthesis rates and frequency of breastfeeding. Two papers showed that there was no difference in milk production 2 and 6 (Daly, 1996) or 7 hours (Lai, 2010) after a feed. The first hour presumably was related to how long it had been between feeding the infant and arriving in the research centre. This shows that as long as infants are fed within 6 hours, there is no effect on milk production. The research reported by Daly and associates using a technique that measures breast volume (1993) shows a relationship between breast emptying and milk synthesis rates, but not nursing frequency. And the research from Kent et al. that weighed infants before and after a feeding found that milk supply depended on the volume of milk available in each breast, whether one or both breasts are fed from, and the time of day, and not the frequency of feeding. Incidentally, my baby’s 6 feedings per day falls within the range in this study. The authors reassuringly concluded “Breastfed infants should be encouraged to feed on demand, day and night, rather than conform to an average that may not be appropriate for the mother-infant dyad.” That’s the key, as long as there are no health issues, babies should be fed when they want and not according to a schedule.

References:

Daly SE, Kent JC, Owens RA, Hartmann PE. Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiol. 1996 Sep;81(5):861-75.

Daly SE, Owens RA, Hartmann PE. The short-term synthesis and infant-regulated removal of milk in lactating women. Exp Physiol. 1993 Mar;78(2):209-20.
http://ep.physoc.org/content/78/2/209.long

Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006 Mar;117(3):e387-95. http://pediatrics.aappublications.org/cgi/content/full/117/3/e387

Lai CT, Hale TW, Simmer K, Hartmann PE. Measuring milk synthesis in breastfeeding mothers. Breastfeed Med. 2010 Jun;5(3):103-7.

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International comparison of breastfeeding recommendations

I thought I would use my international experience to compare breastfeeding recommendations from different countries. I looked up various governmental health organisations and had a look at what they suggest for nursing. And the strange thing is…it is all very similar! That’s right, it looks like six months exclusive breastfeeding is the international standard. Here is a table showing the results of my survey.

Country/Organisation Recommendation
World Health Organisaton Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.
Australia – Department of Health and Human Services Exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond, if both mother and infant wish.
Germany – National Stillkommission WHO recommendations adopted.
Ireland – Health Service Executive Exclusive breastfeeding for the first six months and continuation breastfeeding after that while also providing nourishing solid foods until baby is 2 years old or older.
The Netherlands – Voedingscentrum Exclusive breastfeeding for 6 months, unless the child is ready for complementary foods earlier. Continue as long after 6 months as wanted.
New Zealand – Ministry of Health Babies should be exclusively breastfed until around six months of age, with continued breastfeeding until at least one year of age or beyond.
Switzerland – Schweizeriche Gezellschaft für Ernährung WHO recommendations.
UK – Food Standards Agency Exclusive breastfeeding for 6 months, thereafter until at least one year.
USA – Department of Health and Human Services From birth to age 6 months, feed your baby breast milk only.From ages 6 months to 12 months, keep breastfeeding your baby. You can start feeding your baby cereal or other baby food.For age 12 months and up, continue to feed your baby new foods that are recommended by your doctor. If you can, keep breastfeeding.
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Baby formula advertising – breastfeeding’s foe?

At a certain stage during my pregnancy, I must have landed on a general advertiser’s mailing list tagged as an expectant mother. All of a sudden, the supermarket started printing out vouchers for special deals on infant formula, and samples started turning up mysteriously in my letterbox. I was being inundated with advertising encouraging me to choose formula. I took a photo of the samples that I received, including one packet of ready-made formula in a “breastfeeding” bag from a formula manufacturer (in the photo: a bag of generic formula, two kits of four bottles of ready-made Similac, and a box of Enfamil powder, plus a snazzy backpack). To be fair, the breastfeeding bag also contained some storage bottles for breastmilk and nursing pads. Samples of infant formula make up the bulk of the samples I have received. In contrast, to date I have been given a single nappy sample, even though I have been going through these essential baby items in large quantities and would appreciate more samples of them.

This is one of the big problems with breastfeeding – the financial impact is that mothers save money, rather than paying for formula. There is no business case for breastfeeding that provides a chance for anyone to make money, except the families of newborns who will have lower costs in providing for their newborn. It is very easy for wavering new Mums to decide to formula feed because the have been provided with slick marketing information and samples ready for when breastfeeding becomes difficult. On a few occasions in the past 11 days since my daughter was born, when she has been having difficulty latching or I have been confused by the well-meaning advice about feeding my baby on a two-hour schedule rather than on demand, I briefly considered grabbing one of those little bottles just to be certain that she was eating enough.  And the advertising tells me in reassuring tones that formula helps me to keep me and my baby strong and healthy…

So far, breastfeeding is getting easier and my daughter’s weight gain and dirty nappies gives me confidence that she is thriving without formula. I am keeping the samples to re-gift to a neighbour with an infant once I have passed the three-week mark and I am certain that breastfeeding is working.

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Breastfeeding: my journey begins

My little girl was born last Thursday so it was time to test out what it is like for mothers when they start breastfeeding for the first time.

The first recommendation is to initiate breastfeeding within the first hour after birth. I had a fairly standard delivery, which meant that this was possible for me. So I am happy to report that after giving my wishes to breastfeed before the delivery, the nurses helped me after the birth to start breastfeeding.

My baby cried a lot in the period immediately after the birth, and they also wanted to take her for the important measurements and tests, but as soon as this was done and she had calmed down, she was back in my arms.

I was expecting her to have a stronger rooting reflex when I stroked her cheek. This wasn’t really the case so it took some time to get started. However, once she had latched on, I could feed her for about ten to fifteen minutes sometime in the first hour after birth.

I am happy to report that in the New Jersey hospital I delivered, I was supported in this vital first step to initiate breastfeeding.

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How to get essential fatty acids in breast milk?

As I am still waiting for my little one to make her grand entrance, I thought I would look into detail at a nutrient found in breast milk that seems to be getting a lot of media attention at the moment – the essential fatty acids DHA and AA.

Breast milk contains essential fatty acids – these are components of fats that must be provided by the diet. The most well known essential fatty acids in breastfeeding are arachidonic acid (AA) and docosahexaenoic acid (DHA). AA makes up part of cell membranes and are used to make signalling molecules in the body. DHA is also part of cell membranes, particularly in the retina and brain.

Normal breast milk contains both these essential fatty acids, and their precursors. The concentration of AA is fairly constant at 0.35 – 0.7 % by weight of the fatty acids in breast milk, whereas there is a lot more variation in DHA concentrations from 0.17 – 1.0 % by weight. To put that in perspective, the total lipid content of breast milk is around 4 g per 100 ml.

The concentration of AA in breast milk probably does not change too much because it is synthesised from linoleic acid (LA), which is a significant component of the most widely-used oils in the world (e.g. sunflower oil, corn oil, peanut oil, soy bean oil). The DHA content of breast milk varies more widely – the conversion of DHA from the more widely consumed alpha-linolenic acid (ALA) is poorer and ALA is found in lower amounts in oils used in normal diets. Just to illustrate this point, the commonly used oils corn, cottonseed, sunflower and soybean oil all contain over 50% LA, according to the wikipedia links. The only oil that is likely to be easy to find in the average supermarket with more than 50% ALA is linseed oil, and the more common canola and soybean oil contain only around 10% ALA. DHA is also naturally found in only fatty fish and very few other sources. A company that makes DHA from algae has provided a DHA calculator that illustrates the most common food sources of DHA. So this is probably why there is so much more variation in DHA concentrations in breast milk.

Recently, there have been moves to make recommendations to pregnant and lactating women about how much DHA they should be consuming. Once the concentration of DHA in breast milk exceeds 0.8 % of the fatty acids, there is no further increase in red blood cell DHA and this is considered to be the plateau (Gibson, 1997). Another study found a plateau of 0.5 %, acheived with 200 mg DHA from 21 weeks of pregnancy (Bergmann, 2008). Current recommendations are around 200 mg DHA per day, or two servings of fatty fish per week.

References

I borrowed heavily from the information in this review and consensus statement:

Koletzko B, et al. (2008) Recommendations and guidelines for perinatal practice: The roles of long-chain polyunsaturated fatty acids in pregnancy, lactation and infancy: review of current knowledge and consensus recommendations J. Perinat. Med. 36 (2008) 5–14 DOI 10.1515/JPM.2008.001 http://www.ncbi.nlm.nih.gov/pubmed/18184094

My other references were:

Bergmann, BL et al. Supplementation with 200 mg/Day Docosahexaenoic Acid from Mid-Pregnancy through Lactation Improves the Docosahexaenoic Acid Status of Mothers with a Habitually Low Fish Intake and of Their Infants. Annals of Nutrition and Metabolism. Vol. 52, No. 2, 2008. http://www.ncbi.nlm.nih.gov/sites/ppmc/articles/PMC2790529/

Fidler N, Sauerwald T, Pohl A, Demmelmair H, Koletzko B. (2000) Docosahexaenoic acid transfer into human milk after dietary supplementation: a randomized clinical trial. J Lipid Res. Sep;41(9):1376-83. http://www.ncbi.nlm.nih.gov/pubmed/10974044

Gibson RA, Neumann MA, Makrides M. (1997) Effect of increasing breast milk docosahexaenoic acid on plasma and erythrocyte phospholipid fatty acids and neural indices of exclusively breast fed infants. Eur J Clin Nutr. 51: S78–84. http://www.ncbi.nlm.nih.gov/pubmed/9306083

The DHA calculator is provided by Life’sDHA, and is based on a typical American diet – fried catfish with cornbread and steamed broccoli, anyone? The fish products are the only sources of DHA as far as I can see. http://www.lifesdha.com/dha-calculator.aspx

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