Dr. Stephanie Melka explains the medical side of breastfeeding, and how she has worked to fill the gap between other obstetricians or pediatricians and lactation consultants, who are knowledgeable but don’t diagnose or treat. She shares common advice for mothers on breastfeeding, her own experience breastfeeding, and more.
“Breastfeeding: The Doctor’s Perspective” – with Dr. Stephanie Melka
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Dr. Fox: Welcome to today’s episode of “Healthful Woman.” A podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an ob-gyn and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right. Melka, welcome back to “Healthful Woman.” Glad you’re here to talk about breastfeeding. How are you doing?
Dr. Melka: I’m doing well. How are you?
Dr. Fox: I’m wonderful. You’ve taken an interest in breastfeeding from the medical side of it, and you actually did some extra education and training in it, correct?
Dr. Melka: Yes.
Dr. Fox: So tell everyone what you do. What’s it about?
Dr. Melka: There’s a whole world out there of breastfeeding medicine. And it sort of fills the gap in what physicians don’t necessarily learn in residency, whether it be OB or pediatrics or whatever and the role of the lactation consultant. Lactation consultants are wonderful. They do a lot of teaching, problem-solving, but they don’t diagnose or treat. So, that’s sort of where we come in.
Dr. Fox: Right. And so is that in general what the role of the doctor is, or have you found that that differs from doctor to doctor or from woman to woman?
Dr. Melka: Differs a lot. There’s also a big regional difference. Last year, I did a training course with IABLE in specifically breastfeeding medicine or breastfeeding for the healthcare provider. And what I realized is in New York, there’s so many good services here. There’s lactation consultants. There’s groups that meet that work on breastfeeding stuff, and a lot of other places don’t necessarily have that. For our patients, some of it is patient-driven. Some might have certain medical issues leading them to find a physician. Some are more motivated than others if they’re having problems with breastfeeding. I think it’s also a doctor thing as well. You know, some doctors just don’t have an interest in it.
Dr. Fox: Why do you think that is? Do you think it’s just they view it as not part of their world, meaning this isn’t medical so to speak, or is it just they maybe don’t have experience at it themselves, or because we’re not taught as much during training?
Dr. Melka: It’s all of that. You know, it’s hard to pick up knowledge and do something medical when you’re not taught it in a clinical sense. You know, you can take a course and read and learn about it, but then to actually take that and apply it to a patient, I think, some people are uncomfortable with that. I think some physicians don’t always understand the importance of breastfeeding and why a woman might really want to feed. And it’s easy to just say like, “Oh, you don’t have to do that. Just give formula.” And, I think, they might not see the need as well.
Dr. Fox: Right. I mean, I know for our own training, we learned about breastfeeding, but most of it was really treating complications of breastfeeding like how to treat mastitis or potentially, which is a medical problem, or whatever it is. But there was very little on just normal healthy breastfeeding other than potentially those first, you know, few days in the hospital when we saw the women because we really had no contact with women after they delivered for many months except maybe at their postpartum visit, but usually, you’re talking, it’s already two months afterwards. You know, frequently, they’re doing it or they’re not doing it at that point, and it’s really just a question that we had, “Are you breastfeeding? How is it going?” That was really all it was. When there’s no training, there’s this decreased level of comfort in talking about it because what if she is having difficulties breastfeeding, they’d be like, “What am I gonna do about it?” Like, I go, “Okay.” Okay. You can maybe connect them with someone. You know, doctors get very uncomfortable frequently when we don’t understand something as well, which is a shame because, you know, you could refer to somebody else, but it’s just sort of the nature. And what motivated you to do this extra training?
Dr. Melka: Probably when I first had my now two-and-a-half year old, Alison, and I, you know, was like, “Let me try breastfeeding. Let me see how it goes.” And in going through it, you realize how much misinformation is out there, how a lot of what’s out there is contradictory. You’ll see one resource that says, “You should do this.” And then another resource that says, “Don’t do that. Do this.” And then a third that’s like, “No, all of that is wrong. Try this.” You know, it’s interesting to me looking at the medicine behind it and how all of those things can be right in the right settings.
Dr. Fox: Right. It’s based at who it is potentially. And when you were breastfeeding, was there anything about it that surprised you compared to what you thought it was going into as a doctor, let’s say?
Dr. Melka: It’s really hard. And I had an appreciation for that hearing from women, but it’s hard. You know, I make a living out of functioning on no sleep and of getting up in the middle of the night and doing something and going back to sleep. You know, it wears on you. First couple weeks, you’re up, you know, every three hours, you’re feeding the baby, putting the baby on. And, you know, after a week, I’m like, “Now I understand why women are like, ‘Nope, gonna sleep all night. I’m done.’”
Dr. Fox: And was there anything that you maybe learned about breastfeeding just from your own experience maybe on the medical side that you didn’t learn in training or know as a doctor, or from talking to patients?
Dr. Melka: A lot of stuff about engorgement, sore nipples, cracked nipples, how to tell if the baby’s feeding enough, how to tell if the baby’s feeding too much, how strong is the let-down, like tons of stuff that I just…you know, we get zero education on.
Dr. Fox: As a doctor, when do you start talking to patients about breastfeeding? Is it while they’re pregnant? Is it after they deliver? When do you have that conversation?
Dr. Melka: I bring it up sometime around 28, 32 weeks specifically because that’s when women start looking into getting a breast pump at home and getting it through insurance, and insurances won’t usually cover it until towards the end of pregnancy.
Dr. Fox: What are those conversations like when you have it? Is it just sort of, are you planning on it, and it’s, yes or no, or it’s usually longer conversations?
Dr. Melka: I generally start open-ended, “What are your plans on feeding?” Because I don’t mean for any of this to be pushing breastfeeding if somebody doesn’t want to, or can’t, or chooses not to. I just ask them, what are their plans? And if they say, “I want to nurse, but I understand it’s going to be tough.” And then I start talking about things to start doing now, which is basically like looking into what insurance covers, getting a breast pump at home, getting the extra stuff at home like a comfortable chair, or a breastfeeding pillow, and then there’s a lot of good resources online that I’ll start referring them to as well.
Dr. Fox: And what concerns do they seem to have during pregnancy when they say they heard that it might be hard? Are they talking about sort of logistically or, you know, in terms of their life, meaning going back to work and their family? Is it more just the breastfeeding itself, or is it all across?
Dr. Melka: It’s everything. You know, I think our generation when we were babies, we would be fed, but then we would be given formula. And a lot of our parents will say, “Oh, just give formula. It’s okay,” or women almost find they’re getting discouraged from the start just being told, “It’s gonna hurt. It’s gonna be difficult.” Usually, it doesn’t work out. So, a lot of it is just that emotional support.
Dr. Fox: And then so when you’re addressing these concerns, do you find that it’s more just giving them, you know, positive reinforcements like, “Hey, if you wanna do it, you can do it. We can help. There’s resources,” or is it really actually addressing specific issues?
Dr. Melka: Some of the specific questions I get are about going back to work. And it’s so funny that at 32 weeks, you’re not planning for what, like the first, I don’t know, 6, 8, 12 weeks are gonna be. It’s, “What am I gonna do after that when I’m back at work?” So some of it is like helping with those specifics, some of it is just going over different like support groups, websites, ways to like learn about it. And then some of it is just the emotional. Women have a hard time responding, like if a woman says, “Well, I wanna breastfeed,” and the husband says, “Well, I don’t think you should because of X, Y, and Z.” I think it’s hard for people to navigate those conversations.
Dr. Fox: I think it’s also interesting what you said about returning to work because, you know, sometimes when we’re facing a potential challenge or whatever it is, you know, everyone’s thinking long-term. But the truth is don’t decide now what you’ll do when you go back to work because, first of all, who the hell knows what’s gonna happen? I mean, who could have predicted that all of us would be working from home, right, at this point in time? So you don’t know what it’s gonna be. Some people after they have a baby say, “You know what? I’m gonna change what my work’s gonna look like.” Some do, some don’t. And that’s like a decision that doesn’t have to be made so early. And, I think, most of the data demonstrates that the best way to set yourself up for a longer time breastfeeding is to get it right in the first couple of weeks. If it’s successful, if it’s not painful, if you’re able to do it well, and, you know, sort of get everything set up early, that’s really the key. And so someone who’s, you know, motivated and interested and wants to breastfeed, which is great, I would just say, “Okay. What am I gonna do after the baby’s born?” Like the first day, the first two days, the first week, and focus on that, not so much the long-term planning because the long-term planning will be irrelevant if the first week is very difficult and, you know, you can’t get past that.
Dr. Melka: That’s actually one of the places people get a lot of misinformation. Breast milk supply is all supply and demand, and that’s part of the rationale behind latching the baby very often in the first few weeks. And what a lot of people don’t realize is the baby will transfer milk better than a breast pump. So, some women will say, “Well, I’m not gonna directly feed, but I’m just gonna pump because I’m gonna be pumping anyway when I go back to work.” And that can often set up for difficulty at first because it doesn’t establish as good of a supply, and it’s much more challenging to do logistically in terms of like pump parts and bottles and everything. And again, it’s the right thing for some women. Some women don’t want the physical aspect of nursing. They just want to pump. And that’s fine. It shouldn’t always be the place to start.
Dr. Fox: Right. I mean, all of it is obviously fine, but, I think, also one of the misinformations that women get is regarding the benefits of breastfeeding, which there are obviously. But one of the big benefits of breastfeeding is the actual breastfeeding above and beyond the milk, meaning, in fact, I think, most of the data shows that the breastfeeding component is a huge contributor towards health for whatever reason, whether it’s, you know, the bonding, the skin to skin touch, the warmth. There’s so much about that that we know but don’t quite understand. And then there’s also the milk aspect. And so whatever decision they’re gonna make, obviously is gonna be okay, but it’s just something they need to realize that when we talk about breastfeeding, it’s not just make sure your baby has breast milk. It’s that idea and plus, you know, for mothers that bonding for them is very important and for many women, it is very helpful as part of the recovery from birth. For others, it’s not. You know, for others, it’s just something that can’t sleep anymore, and that’s not a good thing, but for many women, it is really a positive aspect of their recovery. And that’s something that shouldn’t be minimized.
Okay. So you have this conversation with women, you’re talking about it, which is great, and then they deliver. What is your role after delivery in those first few days when she’s still in the hospital in encouraging or helping her with breastfeeding if that’s what she’s doing?
Dr. Melka: So, the biggest thing early on is helping women establish a good latch. How the baby latches onto the breast is sort of physiologic, but sometimes it doesn’t always go well. And that can lead to issue with pain, with decreased milk transfer, and then decreased supply. So, initially, a lot of it is like just hands-on. Like, “Here’s how to hold the baby. Here’s how to hold your breast. Here’s how to get the baby on. Here’s how to make sure the baby stays on. Here’s how to wake up the baby,” all of that stuff. Once the mom goes home, that’s where, I think, the lactation consultants are really helpful. Like I’m not doing home visits, you know, but lactation consultants are. And that is so valuable in terms of, “Let’s look at your physical space. Where are you feeding? Is this physically comfortable for you? Is that what’s leading to pain?” And then from there, women would end up coming back to me if they’re having problems. You know, the most common we see is mastitis. Sometimes it’s just fever from engorgement, overall pain, occasionally, low milk supply, other medical issues that could be contributing as well.
Dr. Fox: Right. I think that a lot of the early breastfeeding instructions help, it come from a variety of people. You know, you don’t need a medical degree. You don’t need, you know, necessarily a lactation consultant degree to help women with nursing. I mean, the postpartum nurses, they do this all day every day with women and, you know, whether they’re formally certified or not, like they know what they’re doing. And so they’re very, very helpful. And for most women in the hospital, either they’ve done it before, or even for first-time mothers, the nurses help them or maybe a family member, and that’s really it. And they’re not gonna require any consultants to come in and help the nurse. But the consultants are there because it isn’t easy for all women, and for some women, even with the help of the nurse or someone in their family, it’s not going right. And the lactation consultants, they’re training. A lot of it it’s so much just experience, right, that they’ve seen a lot of different things, and they’ve seen a lot of common issues, and they sort of understand, you know, the anatomy of it and the physiology of it, like you said. And they just have a lot of, for lack of a better word, tricks for how to get things done in a certain way, and they’re really, really helpful in that regard. And like you said, they’re a resource for women after they go home if available. And, I think, even if they’re not available in your region or maybe it’s cost-prohibitive, there’s so much online in terms of reading, in terms of images, in terms of videos that you can find that can be really helpful. And if it’s not working, you could also go back to your OB and sometimes a pediatrician, depends on, you know, how comfortable they are. And just ask like, how comfortable are you with helping you with breastfeeding? And the doctor will say, “I’m very comfortable,” or, “I’m totally uncomfortable.” I mean, and everything in between. But there are a lot of resources. So let’s talk about some of those complications that you mentioned the women might come back or to see medical care. And when you mention mastitis and engorgement. So explain what those are, and what’s the difference between those two.
Dr. Melka: So, engorgement is when the breast tissues are getting swollen. You sort of have too much milk built up that’s not transferring out. And then mastitis is an infection in part of the breast.
Dr. Fox: Right. And sometimes they’re hard to tell apart from each other sort of on the phone because, in both situations, there’s pain and there’s fever.
Dr. Melka: Yes.
Dr. Fox: And, I think, engorgement is also what happens if women are not gonna nurse frequently will happen to them after birth or if they stop nursing, right, because a certain part of the milk’s coming in, but it’s not coming out. And then mastitis, they don’t have to be engorged to have mastitis. They could just have an infection on the breast. And so how do you differentiate those two let’s say over the phone? How would you possibly figure that out?
Dr. Melka: It’s very challenging over the phone. What I’m finding lately is women are calling me saying, “I have mastitis. I have a red spot on my breast. I looked it up online already.”
Dr. Fox: Google said I have mastitis. Google’s right. Yes.
Dr. Melka: Typically, mastitis presents with a red blotch on the breast. That area specifically is warm, swollen to the touch, whereas engorgement is more general.
Dr. Fox: Right. And as engorgement will frequently be in both breasts, whereas mastitis can be in both breasts, but usually, it’s in one of the two breasts. She can say like, “It’s on, you know, the left side of my right breast.” Like she can say specifically like where it hurts the most, where is that red sort of like wedge that you can see. They’re treated really pretty straightforward. I mean, for mastitis, it’s just typically antibiotics, and she’ll get better almost always. Not always. Sometimes, you know, there’s an abscess that develops and needs like more intense treatment, but that’s really the exception. Pretty much everybody’s just antibiotics. And it’s safe to nurse with mastitis.
Dr. Melka: Encourage to nurse. You don’t want that milk because it’s sort of thought to be a milk stasis issue, where the milk’s not draining, and that’s what led to the infection. You wanna keep nursing or pumping, fine to feed the milk. It’s not infectious in any way.
Dr. Fox: Right. In fact, the bacteria came from the baby’s mouth frequently anyway. So it’s just going back there. Whereas engorgement is tough. I mean, because there’s treatment if she is nursing and there’s treatment if she’s not nursing, right? Why is that? What’s the difference?
Dr. Melka: Well, if you’re not nursing, you wanna be decreasing the production of milk. So you’re gonna be recommending tight bras like sports bra tight, as long as you can handle it during the day and night, ice packs. And interestingly, Sudafed decreases supply. I’ve heard of a couple different dosing regimens, but I’ll usually tell people like follow the instructions on the packaging for whatever formula it is for like a day. And, I think, it decreases supply by like 60% within 48 hours, something crazy remarkable like that. But if you have somebody who’s still nursing, you don’t wanna be decreasing the supply. You want to be downregulating it a little bit because when you’re, again, looking at supply and demand, you’re supplying too much, and it’s not being removed.
Dr. Fox: Right. And the issue is if someone is not nursing and they’re engorged. Yes, if they were to pump they’re gonna feel better, but it’s just gonna keep that cycle going.
Dr. Melka: Produce more.
Dr. Fox: Right. It’s gonna get…either not get better or potentially get worse.
Dr. Melka: Yes. I think there is a role for it like kind of get rid of some of the milk, get some comfort but don’t like pump ’til there’s nothing and then continuing the other measures.
Dr. Fox: Right. And the tight sports bras, you know, their pressure is very helpful. The ice is helpful, not putting a lot of like…you know, when women take a shower, not having as much heat, you know, stand with your back to the shower, for example. And typically, if that’s the reason someone’s engorged, it’s gonna get better within a couple of days. You know, for a couple days, they’ll be sore. They’ll have a low-grade fever. You can take Tylenol. You know, typically, it’ll pass in a couple of days. Whereas mastitis won’t, right? Mastitis can heal itself, but frequently, it’s not going to, and they’re gonna get worse unless it’s treated.
Dr. Melka: You can do a culture of the breast milk, which doesn’t give you an immediate answer but super simple. You just clean the nipple with alcohol and then wash it with saline, and then just have mom express into a sterile cup and the lab can grow out bacteria. Initially, you know, some women are like, “I think I have mastitis. I really wanna take antibiotics. I don’t want this to get bad.” And then others will say, “Well, I don’t wanna take antibiotics. Let’s wait. Let’s see what happens if we’re not sure.” So the culture sometimes helps in that setting as well.
Dr. Fox: Right. And sometimes you actually find it could be fungus like yeast that could be in there as well.
Dr. Melka: I don’t know that that would grow out because, I think, the lab would typically…you know, it’s a bacterial culture.
Dr. Fox: They have to culture it differently. Maybe put in a smear or whatnot.
Dr. Melka: I don’t know how they would do that. I would have to check.
Dr. Fox: What kind of nipple problems do you see women come back with?
Dr. Melka: Typically, general sore nipples or cracked nipples. The soreness usually goes away within a few days, but then the cracked nipples often comes from the baby not latching correctly. So if the baby’s latch is asymmetric, when the baby’s nursing, that suction is gonna be…there’s gonna be an asymmetry of where it’s distributed on the nipple and then leading to cracking or fissures.
Dr. Fox: And then how do you treat those?
Dr. Melka: With saline soaks. You take a little shot glass, and you make like a warm saline mixture. I forget the exact proportions. But you put saline in it, and then just let the nipple soak in it for like 10 minutes at a time a few times a day. And it really helps to clean it and promote healing. There’s different like patches and stuff that people get like hydrogel patches, which can help with healing as well, but, I think, the saline soaks are really underrated for those.
Dr. Fox: What have you found in terms of how charged this is for your patients for women in terms of whether they are or aren’t nursing and how it’s going for them? Do you find that most people are sort of like, you know, they, so to speak, go with the flow, or are people sort of very invested emotionally in this?
Dr. Melka: It’s the number one reason I’ll make a woman cry at the postpartum visit when I ask…
Dr. Fox: That’s nice of you.
Dr. Melka: Of course, “How is feeding going?” And she’ll start talking and then all of a sudden like the tears well up, and it’s like, “I can’t do it. I had to switch to formula,” or it’s, “I’m doing it, but I’m so miserable. I can’t believe like I haven’t slept in more than two hours at a time in the last six weeks.” So it is very, very charged. And, I think, women are very hard on themselves. You know, I have a handful of patients that say, “Yeah, I tried. It didn’t work. So I’m doing some nursing, some formula, and I’m fine with that.” But, I think, there’s a lot of guilt when that ends up happening.
Dr. Fox: It’s a problem that there’s guilt over this. You know, we’re having two podcasts with the woman who authored a book called “Lactivism,” which is basically pro-breastfeeding but anti-guilt for breastfeeding, meaning it’s a decision every woman makes. It is not easy for all women. For some, it’s a breeze, and for some, it’s like, “This is great. I love it. I’m gonna do this for two years.” And others are like, “This is like the worst thing that ever happened to me.” And there’s everything in between. It’s an individualized decision. It’s a personal choice. And it’s not just a personal choice like what’s my preference, but it’s also…it goes differently for different women, and it means different things to different women, and it has a different impact on different women’s lives logistically, emotionally. And so it has to be individualized in that sense. If you had to give sort of your top advice to women who are interested, right? So we’ll start with that group. They’re interested in nursing. They’re excited about breastfeeding. They wanna do it. What would be the advice you’d give them either, you know, beforehand, during, after? Like what are the things that you find are really the most helpful for them?
Dr. Melka: Again, I think, a lot of it is more emotional support than actual medical advice. But I do tell women, you know, “If you have the resources and the means, find a lactation consultant to work with you the first few days.” You’ll have that in…you know, for us, we have that in the hospital, but it’s helpful at home. The physical stuff, again, be prepared with it. And then just emotionally, sort of like birth you don’t know what’s gonna happen until it happens. And as much as there are benefits to it, it doesn’t always work. It’s not always as easy as you want it to be. And you just have to try it and see how things go. Ask for help as you need and work through it as best you can. And I tell people, if it doesn’t work, it’s okay. You know, if you do give formula, don’t think of it as, “Oh, I have to give formula.” It’s that you’re choosing to. That it’s the right thing for you and your baby and your family.
Dr. Fox: Right. I think that’s a great analogy with birth that there’s…you know, everyone has this vision, “Oh, what it’s gonna be like.” And sometimes it works out that way, but it’s unpredictable. Sometimes it doesn’t, and it doesn’t mean anyone did anything wrong, or there’s something wrong with you. Like that’s how it happens sometimes. And the same is true with breastfeeding. It doesn’t always work out the way you think it is. That’s okay. What about for women who come in and say, “I don’t plan on nursing.”
Dr. Melka: Again, I don’t exist to talk people into it, but I usually ask them why. You know, sometimes they say, “Well, my first time it was really tough,” or, “I’ve heard bad stories,” or, “I’m just not interested in it,” and that’s fine. But I often find in that setting I uncover like questions they have or problems that I can, you know, help work through. You know, in terms of not breastfeeding, I don’t give specific formula recommendations. Like there’s a lot of sort of controversy out there now of like U.S. versus European formulas and which ones are healthier. And you have women spending like three times as much money getting like fancy German formulas.
Dr. Fox: Wow.
Dr. Melka: I know.
Dr. Fox: Also I’d imagine what three times the cost of foreign…like foreign is expensive to start?
Dr. Melka: Yeah. I don’t know the exact number. It’s a lot more expensive.
Dr. Fox: That sounds sketchy to me. I don’t know anything about this. That just seems like not necessary.
Dr. Melka: But, yeah, I tell women, you know, “Have formula ready at home.” You know, “Try different types of formulas.” There’s ones that are bottled that are pre-made. There’s the powder that you mix. You know, have the bottles ready at home and then all the engorgement stuff. Have tight bras, ice packs. Frozen peas is a wonderful type of ice pack, you just keep throwing it back in the freezer. And then, you know, starting Sudafed if you’re getting engorged.
Dr. Fox: Right. I think people underestimate the cost both of formula feeding and breastfeeding. There’s cost to both. I mean, it’s obviously time, but even taking that aside, you know, formula is very expensive. But breastfeeding is equipment, right? You know, there’s pumps and the pillows, you know, all the stuff that’s gonna go along with it. I remember when our twins were born and they were not breastfed, and so you’re talking about formula for two kids, and we were, you know, broke, right? So we were like, you know, “We’re gonna nurse.”
Dr. Melka: You were in med school at the time, right?
Dr. Fox: Yeah. It was quite a scene. So I actually found whoever the rep was. There is formula in hospitals for babies who need it, and the hospitals typically get it for free from the companies that do this because they’re thinking, “Okay. If the hospital gives it, then, you know, people go home and use it.” That’s a business decision. Okay. Fine. And so I found the two big companies, and I found their drug rep for the Sinai. And I called both of them. I said, “Listen, I’m a med student. I’m broke. We got twins.” And honestly, they were so kind. I mean, you could say that maybe they’re trying to influence me. I have no idea, but I don’t ever recommend specific formula. But they sent us cases, not cans, cases of formula.
Dr. Melka: That’s awesome.
Dr. Fox: So we had basically, whatever, I don’t know, you know, you feed the formula a year or something, whatever it was, basically for free. It was like the greatest thing that ever happened to our, you know, accounting because we would…
Dr. Melka: That’s awesome.
Dr. Fox: Yeah. Oh, it was so nice of them. I’m very thankful.
Dr. Melka: I’m sure they were trying to influence you.
Dr. Fox: Of course, they were, but I was like, “All right.” But I had both companies working against each other, which was nice. So I’m certainly not biased one of them. I was just very kind to them because, I mean, honestly, if we had to pay for that, it just would have been gruesome. I can’t imagine the kind of debt for formula because my kids ate a lot when they were growing up. Let’s talk about going back to work because that is as you said something people are very concerned about, or they have a lot of questions about. They’re even asking you while they’re pregnant. So first, what was your experience like going back to work? Because I know you went back to work. I know a lot of you did go back to work at some point and you certainly were still nursing at that time. So what was your experience like?
Dr. Melka: I was lucky. I had a very positive experience going back to work. I had an easy breastfeeding journey. I was lucky. I had minimal problems. It went really well. Again, like I handled the sleep deprivation better than anyone, I think. But then, you know, when I went back to work, it was a pretty easy transition. So, you need time to pump during the day, and the time interval in between pumps is different for each person, you know. So if you’re somebody with a low storage capacity, meaning when you pump, you pump two ounces, and that’s it no matter how long you wait, you’re gonna have to be pumping more frequently. You know, some women can hold more milk between pumps and not lose their supply and will only need to pump once or twice during the day. So, logistically, you have to figure out how often that time is gonna be during the day. I think when I came back, I emailed you and OSHA and just said like, “I need time to pump. Like don’t overbook my lunch.” And I’m gonna take like a 15 minute in the morning and a 15 minute in the afternoon somewhere in between patients and just sort of made it work. I would pump on the way to work while driving, which, again, I did not learn about until like I joined a Facebook group of physician moms who were all like, “You have to pump while driving. It’s the best thing ever.” Like this is such a time saver. I love it.
Dr. Fox: You get pulled over, “Hello, officer.”
Dr. Melka: Right. I was waiting for that to happen. I’m sure there’s like easy pass photos of me going over the bridge with like the things set up in front of me.
Dr. Fox: Can you plug it into the car?
Dr. Melka: There are adapters. They make for like the Medela or like full size, not nursing, like travel pumps. Ones that you can plug in. There’s also ones that have a rechargeable battery, but they sell like adapters for the car.
Dr. Fox: Right. Plus I know that you certainly were very comfortable pumping, you know, around others.
Dr. Melka: I was. And, I think, for the most part, people were fine with it. Like I know we had like administrative meetings that I was just like, “I’m gonna be pumping,” and you were like, “Okay.” And like you didn’t bat an eye. It didn’t bother you at all.
Dr. Fox: Whatever. It’s all good. Yeah.
Dr. Melka: Other people not so much. Like other people were like, “I don’t wanna bother you. You’re pumping.” I’m like, “I don’t care.” Like, “Why does this bother you more than it bothers me?” And, I think, that’s a shared experience among women. You know, they all notice. They’re like, “Other people are more uncomfortable with this than I am.”
Dr. Fox: It is a very interesting, I don’t know, psychological or sociological phenomenon about others responses to pumping or nursing around others. I don’t know. It’s so interesting. Like some people walk by like, “Oh, that’s so beautiful. It’s great. You know, good for you. Great,” and others like, “Oh, my God,” and they’re freaked out by it. It’s so interesting. I don’t really understand it.
Dr. Melka: Some people will say like, “You’re uncomfortable because you’re sexualizing it,” and like there’s that whole thing like, “You know, breasts are meant to feed babies. They’re not meant to be sexual. And because you think they’re sexual, that’s why.” Most people I asked because I did ask like when people were bothered by it. They were like, “I don’t wanna make you feel uncomfortable,” and I had to keep saying like, “But I don’t care.”
Dr. Fox: Right. I think it’s just deeper down in the brain than that.
Dr. Melka: I think it is.
Dr. Fox: I think it’s just something that’s just visceral that some people for whatever reason when they were 3 years old. I mean, who knows. But it’s just something about…and because people can’t even, you know, often articulate exactly why they get sort of an odd feeling about it.
Dr. Melka: One person actually…
Dr. Fox: I don’t think it’s sinister in that way. I just think it’s…some people just feel that way. It’s weird.
Dr. Melka: I won’t name who it is publicly, but one person was like, “I just don’t like thinking of you like a dairy cow.” And I was like, “Thank you for being honest.” Like that’s the best explanation I’ve got for all this. Okay. It just makes you uncomfortable. Fine.
Dr. Fox: Yeah. And then I know that also at the hospital, you know, because that’s tough. I mean, it’s hard to carve out 15 minutes at the hospital. You don’t know what’s gonna happen.
Dr. Melka: Yeah. There is a pump room at Mount Sinai. So like there are laws about this like when you have a certain number of employees, you have to have like dedicated space and this and that. It’s in the basement of Annenberg. If you’re walking like to the Annenberg elevators, you’ll…you’ve walked past it and never noticed it.
Dr. Fox: Yeah, sure. No, I’ve noticed it.
Dr. Melka: Probably until I pointed it out to you because it doesn’t say anything on it but it’s one…
Dr. Fox: Right. It’s like a radioactive science, and no one else goes in there.
Dr. Melka: Yeah. There’s three chairs. There’s three of the hospital grade pumps. And there’s no signup. You just like walk in, and if you can use it, you use it. But that also means you have to be able to leave the labor floor to get there. We’ve asked in the past. Then the response is sort of like, “Well, that’s the hospital space. The hospital is not gonna give a shared room in every single building,” which like I get. Like you just don’t have the space for that, especially in New York. But I would usually go up to the call room and pump. I would like bring one of the hospital pumps upstairs and like sit in the call room. And if I couldn’t even leave the floor, I would sit in the doctor’s lounge. I think, you know, one of the OB residents at the time was also pumping, and there were days she and I were sitting next to each other like typing on the computer like, you know, covered up pumping with the little pumps next to us. And half the time people didn’t even like notice what we were doing.
Dr. Fox: Yeah. Everyone’s in their own world there. And also plus like whatever, you know.
Dr. Melka: We had one moment someone came by and was like, “Why aren’t you moving your section?” And I was like, “I’m pumping. I asked the resident to move. I will be back. Like this is not gonna be delayed from me.” And then like one of the women…and like the food got there and like the women are like, “Oh, my God, let me bring you your food” because I’m like attached to the pump like trying to move over to the table to get my food, and obviously, it wasn’t working.
Dr. Fox: Was there anything that surprised you about colleagues or, you know, people you’re around either positively or negatively about your experience?
Dr. Melka: People were very supportive, women who nurse more than women who didn’t nurse and men who had gone through it with their partners rather than men who didn’t. So, I think, it’s like a real…it speaks to like having to actually go through it to understand what it’s like.
Dr. Fox: Like a community. Like being part of the nursing community.
Dr. Melka: Yes.
Dr. Fox: Yeah. Unfortunately, a lot of women don’t have that experience. They find it very difficult, a lot of obstacles, a lot of roadblocks to point, which is unfortunate because it’s like…
Dr. Melka: But, I think, like I would do sections with like you or Barbara, and we’d get towards at the end, and I’d be like, “I’m gonna go pump and do all the paperwork.” And you’d be like, “All right. I’ll finish, and I’ll move the patient.” And like that was it.
Dr. Fox: Right. I mean, because I can’t pump and do the paperwork. So, I mean, maybe like you do it.
Dr. Melka: See, efficiency.
Dr. Fox: Yeah. I mean, one of us has to do it. That’s fine. It’s interesting. When we were designing the rebuild of our synagogue, we actually specifically put in a pumping area.
Dr. Melka: Oh, that’s awesome.
Dr. Fox: It actually wasn’t a pumping area. It’s more of a nursing area because most women weren’t gonna come to synagogue and pump. I mean, some I guess could, but most of them were gonna come with their babies and actually nurse. So we had an area that was for both and it was…I remember vividly because someone actually was really upset at me personally for not designing an area for nursing. I was like, “No, we did.” I showed them, I was like, “Here it is.” I circled it. Like, “Oh, okay, great. Have a good day.” You know, I guess they just assumed it wouldn’t have. I was like, “Yeah. No, we gotta do that.” And then they say, “Oh, it’s because you don’t want to pump in the synagogue,” whatever. It was the whole thing, more like, “Do whatever you want. It’s all good.”
Dr. Melka: You can pump on Shabbos, right? That would be medical.
Dr. Fox: I assume so. I don’t know. It’s okay with me. I don’t know. I mean, again, I think, most…but most people wouldn’t need to pump on Shabbos because they’re gonna nurse, right? I don’t think they want to. I actually don’t know the answer to that question. I’m okay with it. Do you have any tips for women who are going to work themselves?
Dr. Melka: Yeah. The first is just sort of like being open about it like telling your employer like what time you need, like what you need set aside. You need to have milk at home for the baby to feed while you’re back at work. The few weeks before you go back, it’s helpful to start pumping a little bit extra during the day to start freezing milk and having something stashed for when you go back. This is another area of misinformation like you’ll see some sources will say like, “Right away, you should pump twice a day in addition to the nursing, so you can get extra,” and then other places say, “Don’t do that because that’s gonna lead to oversupply.” So, what I usually tell women is if you start like about two weeks before you go back, you’ll get enough. You don’t need like a full freezer worth of milk.
Dr. Fox: You would think if you pump on Monday, that’s the milk you can use for Tuesday.
Dr. Melka: Exactly.
Dr. Fox: Right. You need at least one day ahead.
Dr. Melka: You need at least one day ahead. And, I think, it’s nice to have a little bit extra because like you spill something, or you heat the bottle, and the baby doesn’t take it, and then you can’t reuse it again. So, starting that ahead of time. There’s more devices out now that are designed to collect let-down from the contralateral breast when you’re nursing. So, if you’re latching the baby on the right side, you’ll get a let-down on both sides. And typically, you just leak, and that’s what the breast pads are for. But they make these little like cup with like a hole in it that you just put on your breast, and it’ll collect that let-down, and then you can start freezing that.
Dr. Fox: You just store milk without actually pumping.
Dr. Melka: Without having to pump, yeah, and without having to disrupt like the whole supply-demand thing. Otherwise, I usually tell people like two, three weeks before you go back to work, you know, pump once or twice a day. Morning is typically better. That’s when prolactin levels are higher, so you’ll get more of an output with one pump. You know, usually, I tell people like, “Wake up. Feed the baby. Pump. Freeze that.” And then the day before you go back to work, you start thawing everything out. Helpful but not required to use some of that milk to actually feed the baby at home, like have somebody else give the baby a bottle just so the baby starts learning how to feed from a bottle and not the breast. But there’s a lot of people that will just say like the baby will figure it out. So, that I don’t think is as necessary. So, yeah, have the milk ready. What you pump on Monday is gonna be used Tuesday. So it’s just having that like one day extra and then maybe a little bit more.
Dr. Fox: Wow, that’s great. And what about when women are thinking of stopping or weaning?
Dr. Melka: Go slowly. Stopping all at once is generally gonna lead to issues with engorgement, pain, fever, and higher likelihood of mastitis. So, if it’s possible, I usually suggest dropping a feed at a time if you’re pumping exclusively by that point. Usually, when women are weaning, they’re at work. So they’re pumping and then direct feeding at home, but pumping for less time and then less frequency throughout the day. And it’s just go slowly. You know, you don’t wanna put yourself into an engorgement.
Dr. Fox: Is slowly days, weeks, months? Like what are we talking about?
Dr. Melka: Different for each person. You know, typically, a week or two. You know, I’ve seen some women it takes a month because they drop a pump, and then they wake up, and they’re completely engorged, then they’ll pump out like 10 ounces at a time or something. And it just takes longer for them to downregulate. Again, the Sudafed can help if women wanna go faster and estrogen birth control, you know. So some women also by that time are like, “Okay. I’m weaning. I’m ready to go on combined birth control.” So the estrogen can help as well.
Dr. Fox: Wow. Melka, this was great. Thank you for coming on and talk about this. Thank you for your interest in breastfeeding and for helping all of our patients both in our practice and now out in the world.
Dr. Melka: Of course, thank you.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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