It's too soon to declare victory, but breastfeeding is going SO much better this time around. It's hard to pinpoint the reason (or reasons) for the improvement since we're doing a lot of things differently, but I thought I would try to list the major differences between what we're doing now and what we did with Jude. They are in an approximate order of importance (in my opinion). I think that most nursing mothers who don't have supply issues probably don't need to worry about most of this, but for those people who are struggling or have struggled in the past, it might help to know what is working for me.
Metformin - I was diagnosed with mild PCOS while trying to conceive Jude, and the root cause of PCOS is thought to be some degree of insulin resistance leading to high blood sugar, which prevents hormone-producing organs in the body from doing their jobs properly. When I got pregnant with Ada, I did some research on the link between PCOS and low milk supply, and found that taking Metformin (a diabetes drug which improves insulin sensitivity) in the third trimester (and postpartum) may increase the amount of milk that a nursing mother with PCOS can produce. There is some research currently underway on the link between the two and although nothing is definitively proven yet, early results are encouraging. After discussing this with my OB, we decided that my taking Metformin couldn't hurt, and might help, so I started taking it a few weeks into the third trimester. I really feel like a lot of my issues last time were chemical in nature, and that taking the Metformin has made a big difference this time. I'm planning to continue to take it as long as I'm breastfeeding.
Early Frenectomy - The frenulum is the piece of skin that connects the tongue to the bottom of a person's mouth. If the frenulum is too short, it is difficult to stick out your tongue. For a nursing baby, this makes it hard to suck effectively. There is a history of short frenula in my family - my dad had this problem and so did I (in fact, mine was not corrected until I was two years old and I still remember the surgery). Jude had a short frenulum and it was "released" (that is the verb used to describe the frenulum surgery) when he was about a month old. By then, he'd been sucking ineffectively for long enough that it was difficult to recover a full milk supply. With Ada, I had the nurse check her frenulum in the delivery room within a few hours of birth. Once we determined that she also had a short frenulum, our pediatrician came and did the procedure (called a frenectomy) in our hospital room on Ada's second day of life. She immediately started sucking better and has been going strong ever since.
Different Baby - From the beginning, Ada was better at nursing than Jude. She latched on right after she was born and nursed for over an hour. I don't think she would have even stopped then if we hadn't decided she really needed to be weighed, measured, and bathed. She sucked more vigorously and demanded milk more stridently than Jude in the early days. As Doris says, she "read the manual" on how to feed. If I start to get a little bit lazy and try to make her wait for a feeding because I'm tired, she reminds me that this behavior is not acceptable and that SHE NEEDS TO EAT NOW.
Compressions - The baby sometimes needs help to physically get the milk from the milk sacs (in the back of the breast) to the front where she can extract it and drink it. Breast compressions help accomplish this. Basically, while the baby is nursing, the mom will compress the base of the breast to increase flow and help the baby get milk more quickly and easily. Doris calls this "room service". I noticed a huge difference in the amount of swallowing that Ada did during compressions compared to no compressions. I used compressions for nearly every feeding in the first few weeks with Ada because I didn't yet trust her ability to extract the milk without my help or my ability to produce enough milk for her. With Jude, I used compressions occasionally, but not nearly as consistently.
Nutrition - I didn't eat very well during Jude's first few weeks of life. I was never hungry, I was tired, I was overwhelmed by taking care of a newborn, and food was just not a high priority for me. I didn't eat enough, and I think that's part of the reason I didn't make enough milk for Jude. This time, I still was not very hungry most of the time, but I forced myself to eat a meal 5-6 times a day and drink a ton of water.
Baby-led feeding schedule - With Jude, I was really nervous about having a baby who spent all of his time nursing, so I tried to impose a schedule on him as soon as possible (i.e. "He can't be hungry, he just ate an hour ago!"). With Ada, I pretty much feed her whenever she is awake and showing any hunger cues. Ironically, since my milk supply is much better and she is less hungry, I spend a lot less time feeding her than I did feeding Jude at this age. So my fears of having a constantly-nursing baby if I allowed on-demand nursing have not come to pass.
Skin-to-skin - Jude didn't really like being held all the time as a newborn (from the beginning he liked to sleep on his own). Also, I didn't want to hold him constantly (again I was worried about having a baby who could never be put down). There were a lot of people who were more than willing to take him off my hands when I wasn't feeding him, so I usually handed him over soon after a feeding session was done. Ada and I had a lot of skin-to-skin time during the first weeks and I held her most of the time. She was (and still is) happiest when being held close. Also, handing her to someone else or putting her down was not really an option. E Ben is usually busy with Jude, unless he's sleeping, and we haven't had as much live-in help as we did during Jude's early days. And she usually cried when she was put down, at least at first. She is getting better about being on her own as she gets older.
Close follow-up - Jude lost a pound in his first three days, then began the upward swing in weight. Once we saw that he had begun gaining weight, we relaxed and assumed that everything was fine, only to be surprised at his two-week well-baby appointment to find that he was not gaining weight quickly enough. With Ada, we knew that her weight could be an issue, so we were really on top of the situation for the first few weeks until we knew that she was doing well. I saw Doris four times in Ada's first week and twice in her second week (plus I went in to check her weight on my own one other time). This was helpful for several reasons. First, there were a couple of times when she was lagging slightly and we were able to make corrections immediately. Secondly, when she was gaining well it helped me feel more positive and resolved to continue working on making breastfeeding successful. It's really hard work in the first few weeks (for me, at least) and I think that the positive reinforcement really helped me find the will to carry on.
No antihistamine - Jude was born in the middle of allergy season, and I was taking antihistamines and eye drops in the months before he was born. Afterwards, I continued to take the antihistamines for a few days until his pediatrician told me that this could decrease my milk supply. I don't know if it made a difference, but this was something that I did "wrong" during those crucial first days with Jude. Not this time - I stopped taking the antihistamines immediately and at this point I'm just using prescription eye drops for my seasonal allergies. So far, so good, with that.
Herbal Tea - I don't know if this made any difference, but I continued drinking my Red Raspberry Leaf Tea for the first few weeks after Ada was born. This is one of the main ingredients in "Mother's Milk Tea" and it's supposed to help regulate "the female system". Who knows if this makes any difference, but I like the tea and figured it couldn't hurt!
Of all these things, I think the most significant were compressions, Metformin, and the on-demand feeding that I did in the early days. Of course, it's impossible to know which things made a difference (there's no way to have a control for something like this). But it has been rewarding to experience a relatively straightforward breastfeeding relationship with Ada after all of the difficulties we had with Jude. And having a baby who is not hungry all of the time is great!