Twitter and blog

"Don't offer, don't refuse."

2/8/2022

When a mother decides it’s time to end breastfeeding and she looks for information online, she’s likely to come across the phrase, “Don’t offer, Don’t refuse.” Many sources describe this as a ‘weaning technique’. At least some are prepared to admit this is a ‘gentle weaning technique’. I would like to challenge the notion that it is a weaning technique at all.

Even for those who are practicing gentle parenting and very much aiming to be child-led, I’m not sure it’s an ideal goal we should be endorsing as infant feeding support professionals. I suspect it was not created by someone who is currently feeding a 23-month-old who asks approximately every 30-40 minutes during a day including in the supermarket queue, from the back of the car, while you are stir-frying noodles, while you are caring for a newborn. I’m not sure it was created by someone who is struggling with aversion or who is working full-time (or even part-time). Or someone who would like to stop breastfeeding.

It's a weaning technique if standing in the rain is a ‘washing clothes technique’. You may get there one day, after a long time, but it may not be the most efficient method nor the most practical.

Parents that breastfeed and chestfeed often lose sight of their own needs. Too often I have supported mothers, especially those who began their mothering experience at the start of the pandemic, who slid from babyhood into toddlerhood and have ended up in a situation where they don’t feel confident setting boundaries or feeling they have a right to sometimes say no. Parents are supported to begin with responsive feeding and to respond to their baby’s cues but that doesn’t have to continue throughout a breastfeeding experience and we need to sometimes give parents permission to centre themselves. That could mean deciding to end breastfeeding and practice parent-led weaning. It could also mean being firmer around nursing manners or shaping the day’s breastfeeding in a way that works for everyone.

Don’t offer? Why not? Why can’t someone offer when they are about to go out or they are going to have a bath. Or when they are in the middle of weaning and they say something like, “We can have a short feed now but after that the next feed will be at bedtime.” Modelling body autonomy and demonstrating that these are your breasts and you sometimes get to decide when feeds happen is a powerful lesson for both members of the partnership. You might want to offer because you know that the next hour will be harder or you prefer to feed in a particular location or it just feels like the right time. I don’t believe that sometimes offering is incompatible with bringing breastfeeding to an end. You are taking control of the timing of feeds when it works for you.

Don’t refuse? I dislike the use of that word ‘refuse’. It’s not a word that suggests love and kindness. It implies selfishness and even a bit of brutality. When a parent is simply too touched out to face another feed and suggests a cuddle or reading a book instead, I don’t want that to be termed ‘refusal’. Every parent, even the ones who don’t intend to lead the end of breastfeeding, has a right to decline a breastfeed. What messages are we sending about someone having agency over their own body if every single feed request must be complied with? What opportunities for valuable parenting conversations are we missing? I believe that even the mother who doesn’t intend to take any lead over the end of breastfeeding can benefit from sometimes explaining they don’t feel like doing a breastfeed and that’s OK. Even if that is met with frustration and annoyance, that is part of honest and healthy parenting. Being a gentle parent means encouraging your child to begin to develop a sense of empathy and to start them on the journey of being a caring and emotionally intelligent little person. How can we do that if we are never allowed to show that our feelings and needs matter too?

If you want to end breastfeeding and you are really struggling with your child’s current breastfeeding patterns, please reach out for help. If all you find is the phrase, “Don’t offer, don’t refuse,” keep looking.

If you are happy to continue, remember that your needs matter too and declining to sometimes feed an older nursling is healthy and important. It’s important for your mental health and also important for your child to develop an understanding that other people’s feelings matter and their needs can be met in different ways. This is a two-way relationship. It always has been. Now your child doesn’t depend on your 100% for their nutrition, even more so. Putting boundaries in place and being honest about how you feel is how relationships work. We shouldn’t be endorsing the idea that mothers and parents must always stay silent and compliant.

4 Comments

Breastfeeding after 12 months and dental decay

6/18/2021

3 Comments

Continuing to breastfeed after the first few months can bring some challenges. Sadly, one of the biggest struggles can be dealing with the lack of education in wider society. You might imagine that at least parents are safe when talking to those who are medically trained but unfortunately there are no guarantees.

Parents continuing to breastfeed do report that conversations with dentists can be among the most challenging conversations they have with health professionals.

On a surface level, this is perhaps not surprising. This is a group of professionals who come across children suffering with severe dental problems and at the same time, they may have little or no training in breastfeeding and lactation.

Breastmilk enters the body through the mouth. It contains ‘sugars’. You can see how links end up being made: ‘(Breastfeeding) was not even mentioned, not once. We were taught to advise parents to stop all milk at night after the first year to avoid bottle caries.’ (Richa Sharma, a general dental practitioner in the UK).

Our sympathies lie with parents who are often left feeling unsupported and even blamed when they have followed all the international guidance around breastfeeding.

But let’s feel some sympathy for the dentists too. They often receive recommendations that not only contradict each other but contradict what they see in front of them as they work with families who value breastfeeding. There are dentists out there standing up for breastfeeding and advocating for families but doing so without the full support of their colleagues.

A 2019 study wrote,
"Current recommendations by the European Academy of Paediatric Dentistry, American Academy of Paediatric Dentistry, and International Association of Paediatric Dentistry advocate weaning from breast milk and avoiding unrestricted breastfeeding after the eruption of primary teeth in order to lower the risk of early childhood caries (ECC). However, World Health Organization, American Academy of Paediatrics and nutritional recommendations support exclusive breastfeeding up to six months of age, following continued breastfeeding along with appropriate complementary foods, favouring unrestricted and prolonged breastfeeding even beyond the age of two." (Markovic et al, 2019)

Despite some dentistry organisations claiming otherwise, these researchers stated, “Current literature data revealed possible link between breastfeeding and ECC, however without evidence strong enough for the appropriate oral health preventive recommendation to be provided.”

The bottom line is the evidence is not strong enough to suggest a link with continued breastfeeding and early childhood caries, so in the absence of that link, no one should be telling anyone to stop breastfeeding as if there aren’t any other health considerations to take into account. We are looking at a whole child of course but we don't even have a definitive answer when we're just considering teeth. Studies show that breastfeeding helps to prevent malocclusion. Children that breastfeed for longer are less likely to need braces or correction of their bite. So even if we are talking about just the teeth, some studies are saying ‘there may be a link and more evidence is needed’ and other studies are saying, ‘please continue breastfeeding’.

Speaking on behalf of UK government, Public Health England published a statement, updated in 2019, stressing the importance of dentists supporting breastfeeding and providing evidence-based care. They state:
"Breastfeeding is the physiological norm against which other behaviours are compared; therefore, dental teams should promote breastfeeding and include in their advice the risks of not breastfeeding to general and oral health … Since 2001 the WHO has recommended that mothers worldwide exclusively breastfeed infants for the first six months to achieve optimal growth, development and health. Thereafter, they should be given nutritious complementary foods as breastfeeding continues up to the age of two years or beyond. These guidelines were reiterated in the WHO’s Global Strategy (WHO, 2003) and endorsed by the Scientific Advisory Committee on Nutrition (SACN)."
(Public Health England 2019)

The evidence that breastfeeding up to 12 months is protective of dental health is well-established, or to re-word: that not breastfeeding increases risk of dental caries.

Breast milk, unlike formula, contains Lactobacilli, human casein and secretory IgA among other substances, which inhibit the growth of cariogenic bacteria, particularly oral Streptococci, and preventing it sticking to teeth. Lactoferrin, which is a protein found in breastmilk, kills the bacteria responsible for dental decay (Streptococcus mutans).

Once a child is older than 12 months, the message gets more complicated. Some sources state that continuing to breastfeed after 12 months may increase the risk of dental decay. One systematic review by Tham et al. is often cited as making a link between risk of caries and continued breastfeeding (Tham et al. 2015).

Tham et al. is a meta-analysis, meaning they are assessing and studying previous research completed by others to try and find the big picture. They did note a relationship between prolonged breastfeeding and dental decay but they describe problems with the way the data was collected (sometimes retrospective interviews) and the fact that variables were not sufficiently controlled. Unfortunately this message is often lost when professionals talk about Tham at el. Even The Lancet, in their 2016 breastfeeding series, used this study to assert that breastfeeding beyond 12 months increased risk of dental decay and this was the one downside of continuing to breastfeed.

The authors themselves state that:
"Only a few studies included in this review controlled for key confounding factors and this may have resulted in an over‐estimation of the role of prolonged, frequent and nocturnal breastfeeding in the development of dental caries. Until the dietary and oral hygiene details of these children are controlled for, we cannot be certain whether prolonged, frequent or nocturnal breastfeeding can be principally associated with early childhood caries."
(Tham et al. 2015).

Another meta-analysis also noted a relationship between prolonged breastfeeding after 24 months and dental caries but described this as being based on low quality evidence:
"Of the 13,831 papers identified, 627 were screened in duplicate; of these, 139 were included. The highest-level evidence indicated that breastfeeding ≤24 mo does not increase early childhood caries risk but suggested that longer-duration breastfeeding increases risk (low-quality evidence)." (Moynihan et al. 2019).

Another review, published in 2020 concludes that:
"Breastfeeding until the age of one year is not associated with an increased risk of dental caries, and may even provide protection compared with feeding with formula milk. By contrast, infants who are breastfed beyond the age of 12 months demonstrate an increased risk of caries. However, the results derive from heterogeneous studies that do not always take into account contradictory factors such as eating habits of the mother or infant (feeding during the night, number of meals per day, eating sweet foods, etc.), dental hygiene, or the sociocultural context."
(Branger et al. 2019)

A newer study has provided more reassurance for families continuing to breastfeed. Devenish et al. looked at Australian pre-schoolers in 2020. They studied breastfeeding patterns at three months, six months, 12 months and 24 months. They also looked at the intake of free sugars in the diet. The children had a full dental examination between the ages of two and three to assess the caries rate. They concluded:
"Breastfeeding practices were not associated with early childhood caries. Given the wide-ranging benefits of breastfeeding, and the low prevalence of sustained breastfeeding in this study and Australia in general, recommendations to limit breastfeeding are unwarranted, and breastfeeding should be promoted in line with global and national recommendations. To reduce the prevalence of early childhood caries, improved efforts are needed to limit foods high in free sugars."
(Devenish et al. 2020)

It is certainly true that removing other variables in research is a challenge in this area, as is so often the case when looking at infant nutrition and health. We cannot randomly assign some families to breastfeed, others to not. We cannot ask some families to brush teeth and others to not.

The evidence we have does not convince that breastfeeding to 24 months, or beyond, increases risk of dental caries. Even those who are prepared to state that there is a link will comment on the quality of evidence available and call for more research. If someone claims it is an indisputable fact, we need to consider that they may be basing their opinion more on cultural assumptions about prolonged breastfeeding than the science. If we examine human skeletons from the past, where prolonged breastfeeding and night-time breastfeeding is a given, we see very little signs of decay. It is not unlikely that other variables, such as the increase of sugar in the modern diet are more of a concern, ahead of what is the biological norm.

"Breastfeeding in itself does not cause caries. That would defy evolution as cave men did not give their children milk from other animals let alone formula. The issue is the modern western diet whereby we consume very high amounts of sugar. If we restrict sugar intake to a reasonable level (in my opinion and experience that is fruit after meals and very occasional refined sugar products on special occasions) there is no issue with breastfeeding on demand. Offering cows’ milk or formula on demand once baby teeth have erupted is a much greater issue as our teeth are not designed to consume them. In a dental study conducted in Tristan da Cunha, the deterioration of oral health on this remote island community was noted in middle of the 20th century following a change to a diet rich in fermentable carbohydrates. This confirms the role of sugar in the aetiology of dental caries."
(Dentist Richa Sharma)

The bottom line is that even if a convincing powerful study appeared tomorrow, that had removed all the variables and was flawless in its execution, and it showed that breastfeeding beyond 24 months increased risk of dental decay, this does not mean that extended breastfeeding would not happen.

Evidence is beyond dispute that sugars in the diet and fizzy drinks increase risk of tooth decay, and yet adults and children continue to consume these things, because they are making these choices for a multitude of reasons – pleasure, social acceptance, cultural acceptance. The idea that breastfeeding can be ‘switched off’ and stopped because a professional tells you it should be, puts breastfeeding even lower down the list of what is culturally acceptable than fizzy drinks and juice. If a parent says their four-year-old drinks juice or eats biscuits, the chances are the dentist will accept that and explain what else can be done to reduce risk. At most, they may talk about cutting down or offer a sympathetic approach to changing habits. I have yet to hear of a dentist that says, ‘Why is your child eating biscuits? There’s no value in that.’ Does any dentist say, “You need to stop giving your child snacks?” It goes without saying that it is good practice for a health professional to listen to the families they support, and provide information that supports optimum health of a whole child, not just the bits their training focused on.

What can parents do to reduce risk of dental caries? The list may include drinking a water supply that contains fluoride, no smoking in pregnancy, cleaning teeth properly once teeth appear, regular dental check-ups, minimizing exposure to sugar and understanding that some apparently healthy foods (e.g. dried fruit) may increase risk. Regular snacking in the day could also increase risk. Young children should ideally not be offered sugary drinks or juices as normal drinks.

Families can be supported to make all these changes without changing breastfeeding patterns. The danger of having conversations which focus on the breastfeeding patterns, and criticize breastfeeding choices, is that parents are more likely to go underground. They may continue to breastfeed without regular dental visits and be less inclined to trust other messages being given. This is true of so many conversations with health professionals: when breastfeeding is devalued or dismissed, an important relationship is damaged and the future health of families may be at risk.

We are more than our teeth (sorry, dentists). We are social loving connected humans who breastfeed for a thousand reasons. Even if I come back to revise this article months from now, because a new study has demonstrated beyond a shadow of a doubt continuing to breastfeed is a risk factor for ECC, this article will end will an assertion that breastfeeding continues to aid sleep, calm, provides nutrition and immunological protection and reduces the risk of malocclusion. Only a society that values biscuits over breastfeeding would tell families to stop natural-term feeding.

References:
Branger, B., Camelot, F., Droz, D., Houbiers, B. et al. (2019) ‘Breastfeeding and early childhood caries. Review of the literature, recommendations, and prevention.’ Archives de Pédiatrie 26, 8, 497–503.

Devenish, G., Mukhtar, A., Begley, A., Spencer, A.J. et al. (2020) ‘Early childhood feeding practices and dental caries among Australian preschoolers.’ The American Journal of Clinical Nutrition 111, 4, 821–828. doi: 10.1093/ajcn/nqaa012 PMID: 32047898

Marković, Evgenija & Marković, Dejan & Vukovic, Rade & Peric, Tamara & Kilibarda, Biljana & Vukovic, Ana. (2019). Breastfeeding: The perspective of paediatric dentist. Zdravstvena zastita. 48. 35-41. 10.5937/ZZ1904035M.

Moynihan, P., Tanner, L.M., Holmes, R.D., Hillier-Brown, F. et al. (2019) ‘Systematic Review of Evidence Pertaining to Factors That Modify Risk of Early Childhood Caries.’ JDR Clinical & Translational Research 4, 3, 202–216. doi: 10.1177/2380084418824262 PMID: 30931717

Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec;104(467):54-61. doi: 10.1111/apa.13103. PMID: 26140303.

Public Health England (2019) Guidance: Breastfeeding and Dental Health. UK: Public Health England. Accessed on11/05/21 at https://www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health

Tham, R., Bowatte, G., Dharmage, S.C., Tan, D.J. et al. (2015) ‘Breastfeeding and the risk of dental caries: a systematic review and meta-analysis.’ Acta Paediatrica 104, S467, 62–84. doi: https://doi.org/10.1111/apa.13118

3 Comments

Flat nipples

12/8/2020

6 Comments

Two mothers have flat nipples.

One, in her first conversation about breastfeeding antenatally, was told by a health professional looking at her nipples, “You won’t get any milk out of those!”

The second was told by a breastfeeding counsellor when pregnant, “It’s called breastfeeding, not nipple-feeding. The shape of your nipples have nothing to do with breastfeeding. You’ve got nothing to worry about.”

I’m guessing that the first story gives you a horrible sinking feeling and the second story feels more comfortable but in fact, both mothers feel a sense of resentment when they look back at those early conversations.

In both cases, they feel they were let down. Those conversations haunt them.

I do wince a little when I hear someone trot out, ‘it’s called breastfeeding, not nipple-feeding,’ because it’s not always that easy. We live in a world where so many breastfeeding resources show prominent obvious nipples. If you are preparing antenatally, and you have flat nipples, you will struggle to find a video that shows someone who looks like you. If you are worried about your nipple shape in pregnancy, you need to have a conversation with someone who listens to those worries, talks you through what’s going to happen in detail and will stand alongside you.

Simply saying, ‘it’s called breastfeeding, not nipple-feeding’ is the equivalent of saying, ‘Don’t worry,’ and leaving it at that. More information needs to come next.

Truthfully, flat nipples do bring some challenges. It is unfair to say that it won’t matter. It is unfair to suggest that you might not need some extra support. It DOES NOT MEAN that breastfeeding won’t be positive and successful and you won’t reach your breastfeeding goals but you may need to take more time to find out who is going to help you out in the early days. You may have less wiggle room when it comes to getting positioning and attachment off to a good start.

Babies start to breastfeed when their sucking reflex is triggered. As the name ‘reflex’ implies, this isn’t about a baby choosing to breastfeed, it’s an involuntary process. When the roof of the baby’s mouth is touched, the baby will start to suck. A nipple with some length touching the roof of a baby’s mouth is likely to be a shortcut to getting a feed off to an easier start. If the nipple is flat or if the baby has a high palate, or if both is true, that connection may not be as straightforward. Nor if a baby has issues with tongue function that may make it difficult for them to scoop breast tissue deep inside their mouth and into position. If the nipple is not going to be making easy contact, the baby will need a deep mouthful of breast and to take breast tissue back far towards their hard palate.

Here is Annabel’s story: “I asked the midwife when I was pregnant with my first whether flat nipples would cause a problem and she said no, so I didn’t work out a game plan. I still remember looking at my nipples in my tongue-tied baby post-birth and this sinking realisation that they looked like pieces from two very different jigsaw puzzles. It would’ve been so much more helpful to be prepared that it might take us a bit longer to work it all out and to learn all the things we could do in the meantime. For us that would be: the three keeps, Latch Assist [a product that temporarily extends nipple shape with suction], trying to feed as soon as the baby stirred. Second tongue-tied baby last year and nipples were back to flat, the physical bits were if anything harder but emotionally a whole different experience as I was prepared and had the confidence from feeding my first till two - wish you could bottle that!”

In a conversation about flat nipples on Twitter, Gill Rapley, author of ‘Baby-led Breastfeeding,’ posted, “if the nipple is short, flat or inverted, baby needs to take more of the breast.” It’s a simple message. Once there is contact on the roof of baby’s mouth, just a few millimetres of further movement, that reflex will be triggered. So, these are times to ensure that everyone really understands getting a deep latch is important. Every millimetre counts. We can’t afford to lose them with baby’s hands at their chest, bunched up clothing, the chin not in good contact with the breast or a neck twist. If a baby can’t move their head flexibly and tilt back, the chances of their tongue and chin being where they need to be become more remote.

What are some of the principles we will be talking about after the, ‘it’s not called nipple-feeding comment'?

1. Talking about getting a deep latch (Have I mentioned that yet?).
In times when it may be harder to see a lot of breastfeeding in real life, videos matter even more. Global Health Media’s ‘Attaching your baby at the breast’ is a staple. Their ‘Early Initiation of Breastfeeding’ is useful here as around 7 minutes, you’ll see a baby doing a breast crawl and self-attaching to a flat nipple. It’s important that babies are anchored and secure, but able to move their heads freely. A baby that is dangling under the breast and not feeling supported, is going to struggle to bring their tongue to the right place and scoop breast tissue where it needs to be. If someone is battling their baby’s hands, that’s a clue that baby may benefit from being more prone so the hands are no longer the enemy. We want to avoid positions where gravity is making life harder, it could be making life easier.

In her article, ‘Many moms have been taught to breastfeeding incorrectly’, Nancy Mohrbacher talks through how body positioning impacts on a cascade of behaviours from baby. We want a baby to be able to do what it needs to do, not fighting against a breastfeeding pillow at the wrong height, balancing on a couple of fingers or under a mother who is leaning forward to breastfeed. Nor dealing with a breast that has been pulled over and then inevitably springs back to its natural position when a hand is removed. Nancy Mohrbacher’s videos on natural breastfeeding can help.

2. Talk about minimising engorgement.
Engorgement is the enemy of those with flat nipples. We joke about how a baby latching on to an engorged breast is like trying to get onto a bowling ball, but when you have flat nipples, engorgement is scary. We needed baby to get a mouthful of breast tissue and we needed the breast tissue to be flexible. If the baby can’t move the breast tissue to the roof of their mouth, it could be challenging. And that’s on top of all the other challenges that engorgement can bring like an inhibited letdown reflex and discomfort. We want regular feeding to be happening in those early days. If anyone on the planet is still saying, ‘Don’t wake a sleeping baby’, let’s hope they aren’t talking to someone with flat nipples. We want to talk about reverse pressure softening, using cool compresses to reduce fluid in the breast and some hand expression before a feed.

3. Antenatal expression of colostrum.
Lots of people on social media (who I’ve been asking about flat nipples) said they wish someone had told them about antenatal expression. It would have helped their first few days and elevated their confidence. Hand expression is a useful skill for those with flat nipples. You can use it to relieve engorgement, get some drips to motivate a baby to latch on or get a milk ejection reflex started. Part of the value of antenatal expression is ensuring hand expression feels normal and natural after baby arrives. Antenatal expression can usually happen from 36 weeks and the ABM leaflet is a good starting point: https://abm.me.uk/breastfeeding-information/antenatal-expression-colostrum/

4. Postnatal expression.
Cara: “I think the thing I wish I had felt more empowered to do was give some expressed milk. I waited until someone told me I could even though my instinct was telling me to do something to get more milk into him.” Some mothers talked about receiving the message that early expression was bad or ‘you should wait for 6 weeks’ without realising that if a baby is struggling to latch on, those rules don’t apply.

We have those three keeps: Keep baby close, Keep baby fed, Keep your milk flowing. When latching is taking a bit of time to get established, it can be tempting to spend extended periods trying to make it work, and eventually baby just falls asleep and everyone is exhausted. We need supply stimulated and baby to get milk. Sometimes a baby might start a feeding attempt with some hand expressed milk dripped into their mouth, spoon-fed or syringe-fed to get them into the right gear and motivated to latch on.

5. Does the nipple extend?
Some nipples will extend more. Some may even permanently change shape with feeding and expressing, but in the short term, a few extra millimetres of length can help. This might mean a product designed for the purpose, a short burst with a breast pump, drawing out with fingers, an adapted syringe or using a breast shell. If someone is worried about their nipple shape at the start of their pregnancy, changes may well come. Hormones can change nipple shape and size, but evidence doesn’t suggest using devices in pregnancy will help.

6. Breast-shaping.
Breast shaping can sometimes be a risk. Sometimes it does lead to the breast being pulled across to baby and offered as if someone is bottle-feeding with a breast. But when we want a baby to get a bigger mouthful of breast, it can really maximize those millimetres if done carefully. Techniques like the C-hold, V-hold or flipple may be useful.

7. Nipple shields.
Repeatedly, replies talked about the value of nipple shields.
They may have been used for days, weeks or months but they were often credited with making breastfeeding happen. If we lived in an ideal world, many of these nipple shields would have gone unused and un-bought. High quality breastfeeding support would have been available at any point it was needed and early latching happening without a layer of silicone between nipple and baby.

However, it goes without saying that we don’t live in that world, and to be sniffy about nipple shields may mean some babies don’t end up breastfeeding. Ideally nipple shields are not the first solution (not least because colostrum will get lost inside and not get to baby) but they can have a place. We need parents to understand that sizing is key, not helped by the fact that many shops will only stock a medium.

There is sometimes a misunderstanding that a large size means a large long nipple when in fact, we are looking at the diameter of the base of the nipple. Someone with an entirely flat or inverted nipple may need a large size. The largest available appears to be a 28mm, only available online. Other sizing in the UK, depending on brand, includes 14.9mm, 16mm, 20mm, 21mm, 23mm, 24mm. Forget messaging about sizing according to baby’s mouth; that’s going to lead to sore nipples, compromised milk transfer and reduced milk supply. A nipple will never be drawn comfortable inside a shield if it starts off looking like a hippo wearing a bowler hat. It’s got to be about getting a good fit on the nipple.

Putting the shield on half inside-out, by rolling up the sides and then everting it once it’s in place will create suction that draws the nipple deeper inside and help the shield to stay on. Some expressing alongside shield use and ongoing support from a qualified breastfeeding supporter is likely to be important. Many find that shields end up not being used over time or are only helpful at the beginning of a feed.

The mother from the story at the start who was told: “You’ll never get any milk out of those” went onto say, “5 years of feeding and three babies later. Nipple shields made all the difference and I use them differently with all three.”

There is such a delicate balance in conversations about flat nipples. As breastfeeding supporters, the heart of our work is about building confidence, giving positive messages about breastfeeding and offering encouragement. We are never going to be the ones that start with a ‘Uh-oh, you’re in trouble’ but neither should we be the ones who pretend it doesn’t matter. There are times when breastfeeding may mean more challenges and as always, we give information and build confidence by helping families to feel prepared and supported.

This article previously appeared in the magazine of the Association of Breastfeeding Mothers

6 Comments

Negotiating a 2021 family Christmas

11/20/2020

3 Comments

Ilustration by JoJo Ford

It may be hard at the moment to picture exactly how Christmas might go this year. Usually, it seems obvious: certain family members, expected recipes, that board game, probably that film. They’ll be staying with them. They’ll come over for that meal. You’ll go to them for that meal. Now there’s a breastfeeding baby or toddler in the mix and, for the second year in a row, some uncertainty when it comes to travel plans.

Even just a few months ago, Christmas 2021 looked like it was going to be easier to predict. But now we have a new variant and travel plans are changing again. Not all members of your family may feel the same way about getting together at the moment. It’s a combination that makes it hard to predict what Christmas will be like. It may be that again families don't get to celebrate Christmas in the way they might hope to.

If everyone does get together, you might be in a situation where your baby will spend time with close family in a way they never have before. This may be the first time you’ve all slept in the same house together for an extended period. It could be the first time they’ve been around as you put your baby down for a nap. It may also be a time when the alcohol comes out, and whether or not you are having any, it might loosen a few lips. Maybe people will behave unpredictably. There’s a lot to think about.

There may be other family members who have thoughts running around their head too. They have had some insight into your parenting and your life with new baby but, how are you really coping? You might be practicing responsive feeding and that’s not something they may entirely understand if they parented in the 20th century. These weren’t conversations they wanted to have over the phone or if you were only together briefly, but perhaps during a longer visit, they'll want to ask some questions. For them, breastfeeding was about timing and routines and avoiding ‘spoiling’ a baby or the breast being for comfort. Now we understand much more about the emotional aspect of breastfeeding and the value in the breast being about more than nutrition. We understand that babies can’t be spoiled and responsive feeding helps to develop the right milk supply for your baby, gives them the ability to respond to their own appetite and may help them to calm or even to fall asleep. For many of our older relatives, a baby falling asleep on the breast was a parental failure. For many of us, it’s a useful tool taking advantage of the natural sedatives and relaxants found in breastmilk.

You might be introducing solids to your baby using baby-led weaning and for some older relatives, that all seems a bit odd. How can your baby negotiate a broccoli floret? Surely, that needs boiling and mashing and can only be delivered through the medium of a spoon. Of course, your family aren’t daft. They understand how things change and recommendations change and they are capable of learning and reading but that takes effort. You may not be in the mood to be a one-person early years education tool right now.

Or with co-sleeping (which we know up to 80% of new parents do), you may not fancy explaining lack of risk. Or explaining why you don’t use a cot. Or that, ‘yes, your baby can sleep in a sling and they will be able to breathe’ or, ‘it is OK to have a glass of wine if I breastfeed based on the current evidence’. Or, ‘I have no intention in stopping breastfeeding just because my baby is 10 months old.’

During the last eighteen months, with more parents working from home, a lot of people have continued breastfeeding in a way that perhaps they weren't expecting to. I've also met families who have chosen to continue to give their babies the benefit of the antibodies from the vaccine or to give extra protection to their immune system over the next few months. You may not have expected to be breastfeeding a toddler but now you are and with the holidays approaching, you may be meeting family members who aren't even aware that you are.

All these conversations that normally would have been spread out over months could now potentially be squashed into a few days. It doesn’t feel very Christmassy.

You can take control. If you are spending a moment worrying about the negatives of having family around, there is action you can take. They may be worried too. Not all families are up for the honest and frank discussion option but there are subtler versions.

You might send them an email that says, ‘We’re really looking forward to seeing you but I just wanted to give you an idea of our day at the moment so you know what to expect.’ When you mention meal-times, add in a link about baby-led weaning so they can ‘learn more about it’. Talk about the food your baby has and politely ask that no one else offers other food. Explain that you might pop off around nap time because your baby still breastfeeds before they fall asleep. In the evenings, you may lie down with them and may not be around for a while. Some parents with babies go to bed WITH their baby at the same time and that’s OK too. You do not have to drag yourself back downstairs to have an ‘adult evening’ if that’s not what you want to do and you know you’ll be woken up several times in the night to come. You don’t have to try and fit some imagined version of what your parenting life will be like. Nobody who cares about you would want you to do that.

In that email, you can talk about the ways they can help. It’s a pain in the neck if a guest constantly asks, ‘what can I do?’ The best guests are the ones that never need to ask. You can help by providing a list now: ‘If you are ever stuck for ways you can help, each day there will be a few kitchen jobs written out on a note on the fridge. Folding laundry is always welcome. Wiping surfaces and bathrooms. No one ever needs to ask to empty the dishwasher or empty a sink’.

If you are going to stay at someone else’s house, you can write a note too that explains how your day will go. Just because you are the guest and someone else is the host, it doesn’t mean your role as a parent and your ability to have control over how you parent is changed in the slightest. Make sure you and your partner are on the same page. If your baby finds it unsettling to be held by lots of people (and many have very little experience of being held by strangers), make it clear that once baby is in the sling that’s a sign to everyone that he’s sticking with you.

If you are worried about getting comments about still breastfeeding an older child, remember that you have no obligation to educate others. You don't have to be an advocate for all breastfeeding. It is not your duty to provide links and reading. You don't even have to talk about it at all. It is perfectly possible to politely explain that this works for you and your child and you'd appreciate their support. If that's not forthcoming, you'd appreciate not discussing it. People who love you will get that, even if it takes them a moment. You might be worried that your child will ask to feed in front of everyone. It's this fear that can often be worse than the reality. First off, even if you are the world's most passionate breastfeeding supporter, it doesn't mean you automatically feel comfortable breastfeeding in front of everyone. You are allowed to feel nervous. Secondly, it may be preferable to give your visitors a heads up that your nursling might ask (and this is the word they use) and this is how you'll handle it. It won't remove all the nerves but it will remove the fear of the fear. You can write an email or WhatsApp message and explain what you need from people.

It all sounds really bossy, doesn’t it? Why not? You are the boss when it comes to your own parenting. The guidelines you lay down now about your ability to call the shots will be with you for the next two decades. If you open a conversation now as to, ‘why you are still feeding him’ you can expect a dozen more conversations about other parenting decisions down the line. You don’t have to have conversations about anything that you don’t feel the need to justify. Simply opening some debates implies there are two equally valid points of view and you have to make your case and that’s not true for many things. Even the loveliest, kindest, most supportive family member in the world may think that they are helping by trying to challenge you on a parenting decision you really don’t welcome a challenge on. Of course, we may fear comments and challenges that may never come. Just as we sometimes find the fear of breastfeeding in public is worse than the reality, where no one bats an eyelid and all you get are warm smiles. It might be that the fear of comments is what hangs over you – in the weeks prior to getting together and even in the actual days themselves. Taking control may help you nip it all in the bud.

If you won’t be with family, the video call may be your only contact. It doesn’t have to be an intense long ‘trying to squeeze the whole of Christmas into the slot allowed by your free Zoom account’. Is it really fun to open presents ‘with’ someone over a video call? What can work well is looking at photos and video clips together. Babies aren’t always in the mood when the video call comes around. Just as you sometimes spend Christmas sitting next to someone and looking through photos together, you can reproduce that experience with some video footage. Perhaps show a previously recorded clip of a present being opened rather than try to capture it live. Make a little montage or slide show and talk it through. It can help structure a conversation and babies are notoriously bad at family quizzes.

I hope your Christmas is filled with people bringing you food, cleaning up after themselves and showing kindness. This has been another weird year and Christmas needs to be about rest and togetherness, in the best way we can. It doesn’t have to meet all our dreams. We don’t have to cram in all the conversations. It doesn’t have to be everything to everybody. You don’t have to present a vision of the perfect new family who copes with everything and has all the answers. Be the parent you want to be and encourage the people who love you to come along for the ride.

This article is adapted from an article that first appeared in 2020.

3 Comments

Newborn breast refusal: why didn't my baby get the memo?

10/29/2020

0 Comments

When you were preparing for this breastfeeding thing, you were worried it might hurt. Your sister-in-law worried you that your baby might feed ‘all the time’. You were concerned how you were going to breastfeed in public.

Now you wish you were so lucky to have a baby that ‘fed all the time’. If only you could experience breastfeeding at ALL, even if it hurt a bit. You envy the women who have a problem feeding in Starbucks. You should be so lucky.

Breast refusal is scary. It wasn’t what you were expecting. You thought this little person would come out wanting to do it. No one told you anything else was possible. Your antenatal class teacher showed you some amazing video of a baby crawling up their post-birth mummy’s body and self-attaching. Trouble is - it seems your own baby hasn’t seen the same videos.

The 2010 infant feeding survey says that 27% of mothers stop breastfeeding in the first week because their baby was completely rejecting the breast or not latching properly. There are lots of people struggling with this problem and a lot of breastfeeding counsellors and lactation consultants trying to help them.

Just to say, it is completely normal for babies to sometimes appear to reject the breast in the course of successful breastfeeding. Just like we sometimes don’t fancy a meal, babies are the same. They don’t care what the clock says. Sometimes they are simply too tired or over-stimulated. Perhaps they are dealing with something to do with lower digestion and a poo is imminent. Sometimes they have some upper wind and although they are apparently hungry, it seems like some mysterious force field is preventing them from latching on. These are babies that may take a few hours before they feed successfully again but they will usually get there in the end. If we are seeing wet nappies, periods of alertness and there are no other medical concerns, we may just have to wait a while. We continue to skin-to-skin. We try different positions. It happens in the end.

Newborn breast refusal is a different thing. Sometimes these are babies who did manage to feed a handful of times over a few days but we are usually talking about babies who have yet to latch on successfully and transfer milk. They may refuse to latch at all and bob on the breast in a frustrated and desperate way. Perhaps they may appear at first to latch with the right gape and positioning. It actually does look like those photos from your antenatal class, but when the baby is ‘on’ nothing seems to actually happen. It is like the photo – immobile and not the video version. They just sit there and fall asleep quite quickly.

What are we going to do?

Here are the first four rules when a newborn baby isn’t breastfeeding (credit to IBCLC Linda Smith for the last 3).

1.       Don’t panic.

I know that sounds trite but new mums are awash with hormones and especially if your birth wasn’t what you expected, a non-attaching baby can be a very frightening concept. You really weren’t prepared for this. Does this mean you are never going to breastfeed?

It is very very very important to hear this next part:

With the right information and support, most mums of non-attaching babies will be able to breastfeed after a short while.

There is a small minority for whom there are further complications but this is a minority.

I have known many many parents (and I was one of them) who had a baby who didn’t attach properly for the first few days and went on to breastfeed happily for as long as they wanted to, for months and even years.

I rarely share my own breastfeeding experience but Sam’s story is relevant here. When I was giving birth to Sam in 2004, my labour moved very quickly for a first baby. When I was in transition and felt ready to push, we called the midwife in and she shook her head with a smile and said, “Honey, no. You’ve got hours and hours to go yet. This is still early days.” This was without any examination or having been in the room with me any time recently. It was a back-to-back labour which can be quite uncomfortable and my birth plan suddenly went out the window. I panicked. She offered me pethidine – an opiate drug. I took it. She explained that it was never sensible to give it just before delivery as it can affect baby but this would be OK as I had ‘so long’ to go. Sam was born less than half an hour later. I was 10 cm dilated while she was administering the injection.

Sam was OK but he was very very sleepy and although we had a bit of skin-to-skin (which I don’t remember being called that then); he really wasn’t up to breastfeeding. Luckily another midwife saw the situation and told me to get pumping and syringe feeding. He only breastfed properly for the first time on about day 3. He was initially syringe-fed colostrum and never needed any other milk.

Sometimes non-attachment is about the birth experience. Drugs that relieve our pain can annoyingly affect baby too. The first breastfeed and the first few days can be a far greater challenge when we’re waiting for things to get back to normal.

Research is very clear that even drugs seen as less hard core than pethidine, like those in an epidural, impact on early breastfeeding success over the first 24 hours: http://www.ncbi.nlm.nih.gov/pubmed/12583645

And we can get into a cascade where a mum doesn’t get those early feeds to happen, is encouraged to use a bottle or supplement in another way and she’s then not dealing with the consequences of the epidural but the decisions that led from that.

Some babies born with forceps or ventouse can experience cranial nerve bruising and discomfort which make the mechanics of early breastfeeding a struggle. Unfortunately the baby is unable to convey the fact they have experienced compression of the glossopharyngeal, hypoglossal or vagus nerve so please give them a while. If you have a headache, imagine the act of opening your mouth really really wide or someone holding the side of your head.

Are we saying that all babies who have assisted deliveries or whose mums take pain relief will struggle? No, of course not. Many will be fine and breastfeed well but this is about likelihood. I don’t know anyone who has turned down a forceps delivery when it’s recommended to them and that’s not what this is about. It’s about having information. Talk to your doctor when induction is suggested a week after the due date. What’s the evidence base for that decision because that may increase the chance of pain relief or an assisted delivery and that may make breastfeeding more of a challenge? If you are going down a certain road, know that breastfeeding support may be more of a priority. You may need to place an even higher emphasis on skin-to-skin after birth (though I hope it was high on your list anyway) and you may need a breast pump.

But we’re still not panicking because even if things go initially a bit pear-shaped, it’s likely you can still make breastfeeding happen. You follow these rules. You talk to people around you who know about breastfeeding. You look after yourself. You say hello to your gorgeous new baby who isn’t doing this on purpose and would really like to breastfeed too.

2.       Rule 2 is feed the baby. I know that might sound obvious but you’d be surprised. I’ve known situations where trying to breastfeed takes ages and ages and baby and mum and everyone are tired and baby drifts off to sleep and no actual milk was transferred. Then baby wakes up and there’s another attempt to breastfeed. Sleepy young babies then start to conserve energy and sleep more (which makes breastfeeding even less likely). If we’re going to work on this, we need some fuel. Plus we obviously want baby to be hydrated and not lose too much weight – though it’s important to note that babies aren’t expected to take in a lot of milk in the first couple of days and are expected to lose some weight. We don’t need to glug huge quantities into them. Early feeds are teaspoons worth. However they get the gut moving, get the poo happening and have a PhD’s worth of useful purposes.

Hopefully if baby isn’t breastfeeding, you are being shown how to take the milk out of your breasts immediately. There’s a nice video on breast massage and hand expression here: http://bfmedneo.com/

This is a time when the mums who did some hand expression antenatally are at an advantage. You can read more about that option here: http://abm.me.uk/expressing-milk-baby-arrives-antenatal-expression-colostrum/

You can collect the colostrum in a syringe and ask someone to show you how to give it to baby using a cup or a syringe. I like syringe feeding as it means there is nothing wasted and you can pop your finger against the roof of baby’s mouth and get some sucking happening with the tongue extended over the gum ridge and a rhythm developing. Baby isn’t flat on their back but elevated enough to reduce the risk of aspiration. Baby starts to suck on your clean finger and you reward with a little bit of milk from the syringe in the corner of their mouth. Cup feeding also gets the tongue extended but it’s usually something you need to be taught.

Bottle-feeding isn’t considered first choice because it can teach incorrect tongue positioning, poor gaping and milk will flow without baby needing to use their muscles in the normal way.

However if it’s day three and baby hasn’t fed for eight hours and you are panicking and you can’t get hold of the midwife, giving a bottle may be a more sensible choice than not. You’re just going to try and do in a way that is as close to breastfeeding as possible. Have a look on YouTube for some videos on ‘paced bottle-feeding’. Some are quite extreme but take the principle that we want the baby to create negative space in their mouth and remove milk with effort. If the bottle is more horizontal and the baby is more upright, that is more likely to happen. The milk should not be so fast that the baby is overwhelmed and they are struggling to maintain breathing. Bottle feeding babies have lower oxygenation rates when they are feeding anyway so let’s be extra careful with flow.

We also want a baby feeding on the bottle to have a mouth that looks like a baby feeding on the breast. It seems logical to still hope that the baby will gape with a wide mouth. When they breastfeed, they fill their oral cavity with stuff. It seems sensible to do the same thing when we bottle-feed rather than have a baby nipple-feeding with pursed lips. Let’s put the nipple above the top lip, ‘nose to nipple’. When the baby gapes we will bring the bottle into baby’s mouth when it is still wide. If the baby’s bottom lip is flanged down, that’s a good sign that the tongue is extending over the gum ridge rather than being pushed back as it can with artificial nipples. It may be more difficult to get a baby to do anything other than nipple-feed on bottles that have long nipples and very little silicon areola/ breast behind them. And a word of warning – it’s amazing how many bottles seem to be the “closest to the breast”. It’s never going to be close and it’s going to depend which bit of the experience of breastfeeding you are prioritising. If we used paced bottle-feeding, we can slow the flow so I think it seems wise to try and get a space that allows gaping alongside that.

3.       Protect the Milk supply.

So baby is being fed and at number three, we are protecting the milk supply. That’s still ahead of trying to breastfeed and practising breastfeeding. If we maintain and protect milk supply, we’ll have options once underlying problems have resolved. If we don’t, when baby does start feeding it may not last long if they don’t find time at the breast rewarding.

In the first few weeks, our breast tissue is developing and we are laying down the ground work for our supply that will govern the rest of the time we breastfeed. Stimulating supply now will make difference months down the line. Plus if we don’t protect milk supply, we’re more likely to get blocked ducts, mastitis, engorgement and abscesses.

A lot of people will tell you that colostrum can only be hand expressed. Colostrum is sticky and there isn’t much of it and it can get lost in pumps and flanges. With hand expression, you can gather every drop. However once a day has passed, you may find it useful to start pumping too. It will save time and help your supply really kick in. You could hand express first and then pump for 5-10 minutes. As your milk transitions to mature milk, you may find it’s more time efficient to keep going with just the pumping. Some people find hand expression super easy and continue with that but hand expressing 8-10 times in 24 hours can be hard work.

You can hire hospital grade double electric pumps. Your local NCT branch may have a pump agent. You can also hire direct from ardobreastpumps.co.uk. Pumping shouldn’t hurt and take a moment to check you have the right funnel/ flange size. Your pump rental agent can send out alternatives.

When a baby is non-attaching, a typical day may look like this:

Skin-to-skin, try breastfeeding for 15-20 minutes (if it works and milk is being transferred, go longer!); someone else gives a top-up while you pump. Everyone naps.

Repeat.

Baby will be feeding roughly every three hours (counting from beginning of feed to beginning) with perhaps one block of not feeding as long as 4-5 hours.

Ideally you are one ahead on the pumping. That means you don’t pump while a hungry baby is waiting for your milk. That’s likely to affect the way the milk flows and won’t help anyone. You should be pumping for the feed that comes after.

We often get better pumping results with a bit of breast preparation. Start with breast massage and warm compressions. In research, mums also got a good deal more out when they did some hand expression after the flow from pumping had stopped. Use hands-on pumping to make your session as effective as possible: https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html

Newborn babies cluster feed so you could cluster pump too. Have an hour or so, perhaps in the evening, when you pump for 10 minutes, pause for 5, pump for 10 minutes, pause for 5, repeat.

4.       Work on the Breastfeeding

When baby is being fed and your supply is being protected, you can work on the breastfeeding.

Skin-to-skin is super important (have I mentioned that already?). We try to breastfeed when babies are quietly alert or a bit sleepy or hungry or not very hungry or not very hungry at all. Try it all. You can also try after a little bit from the bottle. Don’t think the breast always HAS to be first and if you’re giving up on the breast, that’s it. You could give 10ml from a syringe, try some breastfeeding, a bit more from a syringe, trickle the syringe over the nipple to encourage some licking and rooting. Move between breast and non-breast organically.

All feeds happen at a naked breast.

Try different positions. Have a look at www.biologicalnurturing.com and try some laid back breastfeeding. Look for Nancy Mohrbacher's materials on natural breastfeeding. See if you can encourage some self-attachment.

How do you know milk is being transferred? You may hear some swallowing but not always. You should notice baby’s chin moving and occasionally pausing to show a swallow. Dr Jack Newman has a video called ‘really good drinking’ that may help: http://www.breastfeedinginc.ca/content.php?pagename=vid-reallygood

If you have very flat or inverted nipples, it may appear that baby is searching for something but not quite able to get purchase and stay on. You may need some help learning how to shape your breast and nipple. You may even end up using nipple shields to help a non-attaching baby attach. Nipple shields get a bad reputation but this is a situation where they can be useful and a baby may end up breastfeeding as a result. It’s always better though to use a shield with some qualified support. They can cause further problems if the wrong sized shield is used, if they are applied poorly and the latch is still a problem.

Getting qualified support is a good idea whatever your nipple look like. You can ask your midwife for local recommendations. Perhaps that person is your midwife or her colleague. You may have a local volunteer breastfeeding counsellor who can meet you at home or who runs a local group. You may choose to pay for a private lactation consultant and you can find one at www.lcgb.org.

It’s also sensible to get someone to look inside baby’s mouth, someone who knows that tongue tie can affect breastfeeding. I know that might sound daft but some healthcare professionals are poorly trained in tongue tie and it’s a leading cause of non-attachment in young babies.

You can read more about tongue tie here: http://www.cwgenna.com/ttidentify.html

Babies can also struggle if they have high palates and this often goes alongside having a tongue tie.

If your baby does have a tongue tie that still doesn’t mean you won’t be successfully breastfeeding soon. You can learn different positions and breast shaping techniques that can help. Your baby may also benefit from a simple procedure where the membrane that holds their tongue tie is cut with a pair of round-ended scissors. This is called a frenectomy. Your midwife or GP should be able to refer you to your local NHS tongue tie service. You can also find private practitioners here: www.tongue-tie.org.uk.

I know this is scary but please believe that if you find the people that can help you this is still likely to work out.

I know mums who have had a baby finally attached at 48 hours, one week, two weeks, three weeks and six weeks. The 27% who gave up in the first week according to the infant feeding survey weren’t speaking to the right people. We were visited at the ABM conference by a mum who attached for the first time at 18 months (that got your attention, didn’t it.) No one can tell you how long to keep going with this but it’s true that you might give up when there’s still a chance your baby will happily attach. You have to decide when it’s right for you.

You could certainly continue exclusively breast milk feeding your baby if that’s what you want to do. I could write another 3000 words on why that’s a good idea. You can read more about exclusive pumping in a useful book written by Stephanie Casemore: http://www.exclusivelypumping.com/

Good luck. Be strong. Find helpers… and did I mention skin-to-skin?

**********************

Is your baby older and was previously successfully breastfeeding?

Some babies may start to refuse the breast after a period of successful breastfeeding. That can also be confusing and upsetting. It can happen as a result of flow confusion if they have had regular experience of bottles. In that situation, you could perhaps speed up the flow at the breast (perhaps by increasing supply or using breast compressions). If you’ve been using bottles a fair bit, your supply may have taken a dip and may need a bit of attention. Breast compressions are useful when the milk starts to get fattier and slower and baby may be finding it a bit harder work. A bit more on breast compressions here: https://www.youtube.com/watch?v=Oh-nnTps1Ls

You can also slow things on the bottle in comparison. The section above on paced bottle-feeding talks you through some of that. If you are confused and unsure, visit your local breastfeeding support group. Don’t think they are just for people with new babies and people who don’t use bottles.

Breastfeeding babies who’ve never had a bottle in their lives can also go on nursing strikes. A self-weaning baby doesn’t give up breastfeeding overnight; it’s normally a gradual and gentle process that takes no one by surprise. It also rarely happens under 18 months old. Nursing strikes can be sudden and with no obvious cause.

Some good thoughts on nursing strikes here: http://www.lalecheleague.org/faq/strike.html

Get your GP to check baby doesn’t have an ear infection and check in baby’s mouth. Could your baby have a blocked nose? Most nursing strikes will resolve within a few days. Feed the baby and protect your supply.

NB: this is a version of an article previously posted under a slightly ruder name. The content is changed only a little.

0 Comments

Lactation cookery or lactation crookery? Why I’m worried about lactation cookies.

7/24/2020

1 Comment

Two of my favourite things in the world are lactation and cookies, so you’d think that ‘lactation cookies’ would be my dream. Sadly, this couldn’t be much further from the truth.

“But what harm can they do?”
“What’s the problem?”
“My best friend makes them and she’s lovely”.
“They taste great and herbs have been used by women for thousands of years to increase milk supply.”
“They really worked for me!”

I am willing to join a throng of my lactation consultant and breastfeeding counsellor colleagues to be a party pooper when it comes to the world of lactation cookies. We would build a bonfire from all the lactation cookies that were given at the wrong time to the wrong people – and it would probably smell quite nice.

1. They can be a barrier to getting the right help.

If you suspect you are struggling with low milk supply, or suspect your baby may not be getting the milk they need, you need support and information quickly. Even delaying that conversation by an extra day could be a problem.

I have just read all the recipes for lactation cookies on the first page on my internet search results. How many of those recipes mentioned that if you do fear you may have some issues with your milk supply, please contact a breastfeeding counsellor, lactation consultant or health professional for support? NONE.

I am looking at a website that is selling commercially-made cookies and at the bottom of the home page we are seeing a ‘seek advice’ type comment. But nothing on the individual product pages. In all the cases I found, any comment about getting the right support was at the end of some text, often at the bottom of a paragraph, and not highlighted.

Milk supply is governed by milk removal. When the breasts are stimulated, we get surges of prolactin hormone. When milk is removed frequently and with an effective latch, the body receives signals to make more milk. For those of us in breastfeeding support, it’s easy to forget that not everyone understands the basic mechanisms of milk production. The more milk that is removed, the more we will go onto make.

As weeks go by, our milk supply settles and we may not experience fullness or engorgement in the way we once did. We need parents to understand how breasts work. As time goes by, the regulation of lactation has shifted to activity within the glandular tissue of the breast rather than being regulated by hormones. It's really common for this altered feeling of softer breasts to be misinterpreted as a sign that supply has been 'lost'.

Oxytocin, sometimes called the hormone of love, regulates milk release. It can be inhibited by cortisol and adrenaline. If a mum is feel extreme stress, perhaps they are expressing on return to work and not getting the results they were expecting, again they may worry milk supply has been 'lost'. Sending this mum off on a journey for lactation cookies, in a bid to 'fix' a problem is unhelpful. Instead we should be explaining how our bodies work, talking about mindfulness and relaxation techniques and ways to reduce stress and increase oxytocin flow.

If someone is worried about low milk supply, it may be that their baby’s latch needs adjusting. It may be that they need to reflect on how often milk is being removed and for how long for. There may be a factor that requires some specialist help such as a baby with a tongue tie, some retained placental fragments or a medical issue. Adding a, ‘Here, try some lactation cookies’ is stealing time and depriving someone of getting information and support that could make all the difference to their situation.

If your best friend makes them, and she is lovely, please ask her to create a banner at the TOP of her website that highlights the importance of getting qualified support and she can throw in some helpline numbers while she is at it. If you sell cookies and it’s possible for me to spend more than 3 minutes on your website without seeing a message about the importance of getting breastfeeding support, you need to change your website.

Sometimes we could be distracted by cookies when an immediate answer is just seconds away: the mum who was worried about their baby’s weight gain but had been told to always restrict breastfeeding to one breast, the baby whose chin just needed to be closer to the breast. How about the exclusively pumping mum who felt desperate when her pumping output dramatically reduced but her pump just needed replacement parts? All the cookies in the world are not going to repair her pump valve. All the cookies in the world won’t change your baby’s positioning.

2. Some of the ingredients could do actual harm.

Cookie is a word that sounds so harmless, but that friendly word is masking a potential risk. Lots contain a seed called fenugreek. Fenugreek has been used around the world to support lactation for a long time but just because something is a plant and ‘natural,’ it doesn’t mean it’s safe for everyone to ingest. The evidence on whether fenugreek does aid milk supply is patchy. There are some studies that suggest it could, but we also know that some people should avoid taking it.

Post-partum thyroiditis affects about 5-10% of new mothers. That’s a surprisingly high number and potentially a significant proportion of those struggling with supply issues. It may start out with hyperthyroidism (which could mean a strong milk supply) and then shift into hypothyroidism (when milk supply could be negatively impacted). Lisa Marasco and Diana West, in their book ‘Making more milk: The breastfeeding guide to increasing your milk production’, talk about the association between taking fenugreek and lowered milk production. Fenugreek is also not recommended if the parent has diabetes, hypoglycemia, asthma, a peanut or chickpea allergy or a bleeding disorder. We also have cases of it causing gastro-intestinal issues in both mother and baby.

I have spoken to mothers who took weeks and even months to get a diagnosis of thyroid issues, and during than time milk supply was a worry. If they had been buying and eating lactation cookies throughout that time (and one had), it could have made the situation worse. Imagine the mum with undiagnosed thyroiditis feeling she just hadn’t ‘found the right recipe’.

When we are a new parent, we are very vulnerable and if a bunch of people are telling you lactation cookies are the go-to, why would you not believe them? Guess how many of those recipes I checked mentioned that some of the ingredients may not be safe for everyone?

Brewer’s yeast is another commonly used ingredient. It tastes bitter in large quantities so is often used sparingly. Maybe that’s not a bad thing when you consider that it interacts with more than 200 medications. It interacts with some medications used to treat depression and as you can imagine can impact on anti-fungal treatments.

3. Even if they are safe for you to use, what messages are being reinforced?

Let’s imagine your thyroid is fine and you don’t have an underlying latching or breastfeeding management issues and you just fancy some lactation cookies. I would still argue that you are receiving a message that your body is insufficient. One of the biggest arguments pro-lactation cookies is that they are a placebo and they often have a positive impact because we BELIEVE that they work. Perceptions of low milk supply are widespread among new parents and in the majority of cases there is nothing to worry about. It’s normal for babies to sometimes be fussy, for breasts to start to feel softer, for leaking to stop, for pumping output to shift, for feeds to get shorter in length.

I would much rather that the placebo, which may cause parents to feel more relaxed, is a dose of accurate information about how breasts change and how babies behave, what growth spurts are and what’s normal in lactation. I don’t want someone to spend £10 a box for that sense of calm or a feeling that they are ‘doing something’. When we are telling new parents that breastfeeding means eating and making lactation cookies, we are telling them that bodies don’t work on their own. We are saying that low milk supply is the norm and we need help to be mammals. We already live in a society where breastfeeding is often not trusted. I don’t feel the answer to this lack of confidence is to imply cookies will fix us. Do we really want a placebo that normalizes perceptions of low milk supply?

4. They are often expensive.

Here is one company selling 500g of lactation cookies for nearly £10. Here’s some more for £14. Here’s a monthly subscription for around £50. Even if you make your own, some of the individual ingredients can really add up. Oats are a staple of many recipes. They are not expensive. Does that box really need to cost £14? We know new parents often feel that paying more means a product will be better quality. We are a vulnerable bunch. Flapjacks made with oats and some flaxseed are going to cost a fraction of some of the commercial products. You can get a packet of oaty biscuits from a supermarket for about £1.

Let’s be really careful about lactation cookies. For the minority who do have genuine supply issues, there may be better galactagogues (substances that increase milk production) that they should be signposted to. Even if you have researched fenugreek and other herbs carefully, and feel they are worth trying, there are other ways to take them that are cheaper and more easily controllable and potentially in more useful quantities.

Jil (@midsussexdoula) on Twitter pointed out that men struggling with erection problems wouldn’t be palmed off with ‘erection cookies’. They would expect knowledgeable support.

If you feel lactation cookies helped you, your role as a supporter of others is not to suggest lactation cookies before you suggest anything else. You could be delaying someone from getting the help they need and wasting their time and money. If you absolutely believe that lactation cookies had a magical effect on you, you need to work even harder to check yourself before you mention them.

And finally, cookies are good. Eat all the cookies you want, just because they are cookies. Find ones that taste nice, make you happy and bring positives to your life. This is not an anti-cookie message, this is an anti-'cookies that undermine breastfeeding' message.

1 Comment

Toddler twiddling

7/6/2020

2 Comments

If you spend 10 minutes in a social media group where breastfeeding older children is the norm, you’ll come across the topic of toddler twiddling.

Toddlers enjoy fiddling generally: the little plastic figure in their hand, the toy car, your car keys, your glasses. It’s how they explore their world, develop their fine motor skills, calm themselves and occupy themselves.

And when they are breastfeeding, the other nipple often looks like another appealing button. Some stroke, some twist, some pull, some rub between a finger and thumb, some twiddle to get to sleep. And the nipple-owner is often struggling. If it doesn’t bother you, you can ignore this conversation. But too often, we are uber-bothered.

If your toddler enjoyed poking you in the eye during breastfeeding, how many times would you tolerate that?

I’m thinking perhaps once or twice.

Imagine if their favourite thing was fiddling with your eyelashes? Imagine the sticky little fingers and teeny fingernails. That’s going to happen for half a day MAX. We’d say things like, “I don’t like that. That hurts my eye. That makes me feel uncomfortable. Please don’t touch my eye.”

Too often, I’ve seen breastfeeding twiddling tolerated even when it bothers someone just as much.

I think because it’s the nipple, we somehow feel as though it’s part of breastfeeding. We might read something about how the nursling is stimulating a letdown reflex and think, ‘it’s natural so I’m stuck’. Or because you can see it gives them comfort and soothes them, you feel obliged to tolerate it. Of course, it often creeps up on you. Sometimes literally (with a hand suddenly thrust down your t-shirt) but I also mean figuratively. It starts when they are small when it doesn’t bother you that much and gradually becomes the norm without you ever having remembering consenting.

And consent is a relevant word here. I say this a lot when I talk about breastfeeding older children, this is their first intimate relationship. This is a model for how important relationships are going to go in their life and it’s about far more than milk delivery and about far more than their comfort. You are teaching them slowly and gradually, that you are a person too. Child-led weaning is not a scenario where empathy has been removed. Natural-term breastfeeding is not about teaching your child that your feelings don’t matter. What a waste of a vital life lesson.

When breastfeeding starts out, they don’t even realise you are a separate person. And often, we don’t feel like a separate person. But as the months and then the years go by, that changes and it should change. We have times when we have to do something else. We have times when we have to care for someone else. We have times when we have to care for ourselves. We have times when we don’t feel like breastfeeding.

Too often we think that the phrase often used in conjunction with natural-term breastfeeding, “Don’t offer, Don’t refuse” means that to ‘refuse’ is a betrayal of breastfeeding. But refusal (or let’s call it ‘negotiation’ instead) is a cherished opportunity to teach that humans in this world become better humans when they care about others.

An 18-month-old, or even a 3-year-old, is going to struggle with genuine empathy. They are often self-centred in a positive and wonderful way. But how does that phase end? Not by some magical delivery from fairies at around 5 or 6 or 8 or 9 years old. It happens slowly slowly. Even newborns react to a human face in distress. Day by day, piece by piece, a little brain changes and gets that others have feelings too.

Breastfeeding is a wonderful tool for teaching the skills that are at the heart of being a human. When you say, “I don’t like it when you fiddle with my other breast”, you are helping to make a person who will form healthy relationships decades from now.

There are some practical tips that might help:
- You can tuck a piece of cloth or something textured into your clothing and encourage fiddling with that as an alternative.
-Offer a knitted breast, or even a silicone one.
-Move their hand to a different place with a gentle and repetitive phrase and be consistent.
-Let them say one ‘hello’ and then give them a choice about where the fiddling will continue: Do you want my bra clip or your nose? Do you want red flannel or shirt button?

Motherhood and parenthood feel like the lands of sacrifice. We are constantly absorbing the message that our feelings come second (or further down the line). If we have made a choice to continue with breastfeeding, we sometimes feel as though we have signed up to some sort of deal where we have to pretend it’s all wonderful. We’re not supposed to want to make restrictions. We’re betraying the God of natural-term breastfeeding if we do.

This is not true. If the nipple twiddling is uncomfortable for you, end it today. On a practical note, this means more oxytocin and more milk flow and an improved breastfeeding experience for all. It also means your mental health and the ability to see a breastfeeding session as a positive experience is elevated. It could even extend your child’s opportunity for more days, weeks or months of feeding because you’ll be happier to continue.

If your toddler was poking you in the eye, you’d say ‘no thanks’. They might protest. They might get cross. You’d still say, ‘no thanks’. If they want to fiddle, there are infinite other options that give you agency over your other nipple. Toddler twiddling is not something you have to put up with because your feelings aren’t the priority.

Natural-term breastfeeding is about more than anti-bodies, protein, Vitamin A or even comfort. It’s a world where you have a fast-track way to create a little human filled with empathy and kindness. Use that opportunity.

I’ve talked previously about the challenges of breastfeeding a toddler when you are staying at home more than usual: https://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/breastfeeding-a-toddler-or-beyond-during-lockdown-the-best-of-times-and-the-worst-of-times
And I have an article about stopping or restricting breastfeeding when you are feeding a toddler or pre-schooler: https://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/category/weaning-toddler-bob-and-preschooler-billie-how-do-you-stop-breastfeeding-an-older-child

2 Comments

35 activities for children during #StayAtHome

5/7/2020

1 Comment

Every day since the #StayAtHome order began in the UK, I have been posting a daily activity for the children of volunteers of the Association of Breastfeeding Mothers.

Our amazing volunteers have been answering calls on the National Breastfeeding Helpline alongside Breastfeeding Network volunteers, offering remote and video support, continuing with their training and helping to train others, administering Facebook groups as well as looking after their families and continuing employment where possible.

You may find some of these activities are useful for your families too. Many can be adapted to be used with different ages.

I also had help from my fabulous assistant Emily Bruce who is 9 years old.

1. Make a mode of transport. It could be miniature (for a toy, hamster or imaginary creature) or it could be person-sized. Can you design it on paper? But then maybe make the real thing too?

2. Do you have any egg boxes around?You can use them to make a floral wreath. Here’s a video that explains:
https://youtu.be/eCxSCd6Bqo4

3. Painting on a window is a great way to decorate your home and cheer up people who might walk by. And you can make your own window paint. https://www.kidspot.com.au/things-to-do/activities/craft-activities/how-to-make-window-paint/news-story/223b3c2b2bde6e1965f19f1b57655c28?fbclid=IwAR1_XWTgQAPr09-htPvDELhJIATLOCICPEKZCh4m5osrIZAAsBF6gC9N9YM

4. Make a mini garden. You could make one for a little toy. Or make one for a fairy or friendly mouse who might visit one day. You could make it on a plate or on a tray or in a box. You could use things from outside like stones and leaves and twigs. Or you can use inside things like paper and cardboard and lettuce and play dough. Or you can mix inside and outside things.

5. Can you make your own butter? You need a jam jar and some cream (you can do it with milk too if you are very patient). Skimmed milk doesn’t work very well. Why not? When you have finished, do you like it better with a little bit of salt or without? https://happyhooligans.ca/homemade-butter/?fbclid=IwAR1C_edNM6qgpyE2ZSYGPctTXKmd22qeINWX8HyqOIeiznIhSlw1SQMnSnc

6. I saw on Twitter a teacher set her class the challenge of presenting baked beans as if they were chefs at the fanciest restaurant in the world. If you don’t eat baked beans, choose some very ordinary every day food and go for the fanciest presentation you can.

7. Play a game called cat’s cradle. You need a piece of string or wool about a metre long. You might need to try different lengths. Essentially you’re going to tangle your hands up in the string but in a cool skillful way. Watch these videos to see how it works. Solo cat’s cradle: https://images.app.goo.gl/WKXJ4MiNhS8Hfr4v5
Two people version: https://youtu.be/VpHTPnrYLzQ

8. Make musical instruments. Can you use things from around the house and garden? Musical instruments make sounds with blowing, plucking, banging, shaking. Even a piece of grass can be a musical instrument. Emily says snail shells make a good clacking sound (but snails would probably prefer to be finished with them first). Then can you put on a performance!

9. Throw things. Get a cup or a bowl (plastic is better). Put it on the floor. Take a step back and throw a penny into it. How far away can you step back and still get the penny in? Or you can try playing cards (which will be useful if you are ever a cowboy or a film character who is bored). The playing card throw needs a quick flick.

10. Salt dough is thought of as a Christmas decoration thing but you can make salt dough any time of year to make lots of different ornaments. https://www.yummytoddlerfood.com/activities/the-best-salt-dough-ornaments/?fbclid=IwAR3ClTliU9cwLJryYIuOTDfgNn0eRA8-CyNzYWMVz-KRmkzzu3t7E15ktI4

11. You can take a virtual tour. You could do a drawing of something you saw on your trip.
Baltimore aquarium: https://aqua.org/media/virtualtours/baltimore/index.html
Metropolitan museum in New York: https://www.metmuseum.org/art/online-features/met-360-project
The National museum of the US Airforce: http://www.nmusafvirtualtour.com

12. You need string or wool, card and colouring pencils or pens to make a SPINNER. I’m not talking fidget spinners. I’m talking about spinners that go zoom with string after you've spun them round. They make look a bit uninteresting when they are still but trust me, when you get spinning you will go WOW. Which patterns look particularly cool? Maybe you can share a mini-video of your spinning. Instructions here: https://www.easypeasyandfun.com/how-to-make-a-paper-spinner/

13. What can you make out of a towel? Or a mini-towel? (Otherwise known as a flannel). There are many possibilities. It could be part of a landscape for trains or cars. It could be part of a costume. Or it could be an animal. This video helps you make towel animals: https://youtu.be/w4sb6OAnvAY

14. Learn the BSL alphabet. BSL means British Sign Language and it’s a language often used by deaf and hard of hearing people in the UK. There are thousands and thousands of BSL words like there are in every language but you can also learn the alphabet to spell words out. Can you learn the alphabet? Can you learn how to spell your name?
https://youtu.be/DgIvXXdwjvw
You can learn some of these 100 common words too: https://youtu.be/gMNHvXSW4iE

15. Get to know Joyce Grenfell. Listen to her here: https://youtu.be/ZXhHFgDRNBQ What do you think? Can you listen all the way through without smiling at all? If you enjoyed that, you can try: https://youtu.be/vTqivGLAZXM. And https://youtu.be/8iWl36mh6vM

16. Make today SOCK day. What can you make out of an old sock?A cool sock puppet is always a good thing but think BEYOND THE SOCK PUPPET as well. It could be something for a toy, something useful in the kitchen, something practical for another part of the house, something very very silly. What can you do while wearing socks on your hands? What is the most challenging thing you can do? Can you wash up? Can you brush your teeth? Can you tie shoelaces? Can you type? Can you eat a banana? What other challenges can you complete with sock hands?

17. There is a book called ‘Paper Dolls’ by Julia Donaldson and Rebecca Cobb. In the book, a family make paper dolls. Every doll is a different little character. Have you ever made paper dolls? There’s a video that shows you how to here: https://youtu.be/CYXxoVbPzqI What little friends will you make?

18. What birds do you share your neighbourhood with? If you have a garden, do you know the names of all the birds that live with you? Can you record the birds you see over a week? Which one is the most common? What birds can you see and hear when you go for a walk? Lots of birds are making nests at the moment. You might see them collecting food for their babies too. https://www.rspb.org.uk/birds-and-wildlife/wildlife-guides/identify-a-bird/

19. Have a look at the work of Canadian artist Raku Inoue. He makes insects using things he finds in the natural world. Can you have a go? You might be able to do it from things you have inside the house too. What about a bug made from nothing but types of breakfast cereal.

20. Today (and you may or may not already know this) it is one of your favourite toy’s birthdays! Why don’t you throw them a surprise party! You can make them some decorations, wrap them a little present (and decorate your own wrapping paper), have a special meal, send party invitations, play some party games with them and their friends, have a birthday disco. Happy Birthday __________! (If you don’t celebrate birthdays, maybe 2 toys are having a wedding anniversary).

21. WHAT IS YOUR DREAM PET? I don’t mean - I’d quite fancy a hamster right now - I mean you can have ANY animal or creature from across the world, from history, from your imagination. They will live with you by choice and be your loving friend.You can draw a picture. Describe them and someone else can draw their picture. Make a model. Write a description or a story. Dictate a description to someone else. It would be nice to know their name.

22. How many pieces of clothing can you wear at once? I would add that you can’t wear anything that covers your face and you need to put all the clothes back again afterwards! But how many individual bits can you fit on yourself and still be able to walk?

23. Teaspoons have a tough life. They live in a drawer. Then someone takes them out, sticks their head in hot water and spins them round in circles. Then shoves them in soapy water. They see so little of life. I would like you to choose a teaspoon and give it THE BEST DAY OF ITS LIFE. Make it a little house, an outfit, show it your favourite film, put on a concert for it, give it a spa day. Give it a NAME. Make your teaspoon’s dreams come true. You may think teaspoons don’t care. But what if they do? Think of the stories it will tell the other spoons back in the drawer.

24. Be a cobbler. Make a pair of shoes. Use any materials you like.

25. Limit your language. Look online for extracts of novels called ‘Gadsby’ and one called ‘A Void’. They were written entirely without using the letter E. Can you write a story without using the letter E? Or how long can you go without saying: I, THE or AND. Can you tell a story about a trip you once went on without those words?

26. Make a family newspaper or magazine. You could interview members of your family, include recipes, make a crossword, review a film, discuss sporting events (which may just be ones that happen in your garden). You can invent some adverts too.

27. Have a go at writing an invisible ink message using lemon juice. You could even draw a picture and post it to someone (and give them instructions how to see it). https://youtu.be/poCnU_crpjQ

28. Do you like ketchup on your cornflakes??This is the title of a great split-page books.You can see someone reading it on a video on YouTube here. https://youtu.be/yfqHI-oMuYA
You can make split-page books that make funny faces, make characters that wear funny clothes or monsters. You can use them to tell stories or write poems. Can you make a split-page book?

29. Make a time capsule. A time capsule is a collection of special things that tell people in the future what life is like now. People get a box or a tin and fill it with notes and objects that tell people about the world they live in. Sometimes we hear about people making a time capsule that gets opened 100 years later and the people who made it aren’t around any more. I’d like you to make a time capsule for your future self. You might open it when you are 30 or 50 or 80! What will your life be like?! Whatever you are up to, I think you would be interested to get a message from the year 2020. You could draw pictures, write a letter, put in a photo, put in a little toy, something about the news, a food wrapper. The possibilities are endless. But it will be something you won’t see again for a long time. Tell your future self how you are feeling today.

30. Make a laser maze. Sometimes lasers are used to keep precious things safe in museums (but often in films about museums and banks because lasers look cool). It’s very hard for someone to wiggle past lots of lasers without touching them and setting off the alarm.If you have wool at home, you could make your own laser maze. User a timer to see how long it takes you. If you touch the wool, you have to start again. If you don’t have any masking tape or you don’t want to stick things to the wall, you can also make an obstacle course on the floor. Can you hop your way through your maze without falling over? You could use a timer to see if you can get faster.

31. You know those cardboard circles that come under shop-bought pizzas?They are about the size of a big dinner plate if you have any cardboard and you want to make your own. What can you turn one into? Stare at that circle. What could it become? You can draw things, paint things, stick things. It could be a face, a planet, a meal. There are so many possibilities!

32. Make a foil animal. You may have some foil in the house. Perhaps it was wrapped around an Easter egg. Can you make a little animal using foil?

33. If you have the ingredients at home, can you make your very best sandwich? If you don’t have the ingredients at home, can you draw a picture of what your imaginary sandwich would be. Sometimes people draw sandwiches in a special way so you can see all the different layers of ingredients. You could make a poster to advertise your favourite sandwich. Or even make a little video which is a television advert for your sandwich.

34. Make your best CIRCLES. Please use objects around your home and garden to make some art (objects that don’t normally get used for art). You might use leaves, Rice Krispies or Lego. Look online for the work of artist Andy Goldsworthy who uses things he finds outside.

35. Imagine you could go on holiday to a magical island. What would be on your island? It’s magical so it can be anything your mind can create. Maybe it has different areas that members of your family will especially love. I’ve got a cliff with some puffins nesting because my family like bird-watching. And a LOT of restaurants for me. What’s on your island? You could make a map.

A message from Ann, an ABM breastfeeding counsellor volunteer:

My husband, Andy, is a kind and brave man. Whilst I spend my working life helping families with breastfeeding, he spends (or 'spent') his working life organising bespoke cycling tours for small groups. Once C-19 struck, and 'lockdown' started, my work ramped up into a whole new gear. Many many hours of work, some of which is paid, all moving into new ways of working online and on the phone. Energising, yet deeply exhausting. For Andy, as for so many other people around the world 'lockdown' meant the end of his entire summer season. No work, no income, no plan for the future.

For many of us, our work is part of our identity: what we do with our time, and what we feel passionate about is part of what makes us get up in the morning and feel good about ourselves. If 'lockdown' took this away from you, I feel for you. I've been extremely lucky; Andy hasn't been, and that's true for many other people.

Whilst coming to terms with the shock of sudden unemployment and loss of income, in observing my long hours of work at the dining table, Andy saw the effect of 'lockdown' on the many families having babies during this time. Where is the support? The face-to-face encouragement? The knowing smile on someone's face as they pass a new parent the first hot cup of tea they've managed to drink for days? Andy also saw how hard many folks in the voluntary sector are working right now, to reach and engage with those families who want or need help and support with feeding their babies. Finding new and creative ways to give families the help and support they want, but without leaving our homes.

So he decided to help by wearing some rainbow knitted boobs.

He created #BikeAndBoobs

Andy likes to have a cycling challenge to get his teeth stuck into, and getting out on his bike every day is part of what keeps him - and by extension, me - sane. Instead of the Lands' End to John o'Groats trip he should have been doing right now, he's doing his daily permitted exercise weaning these jaunty boobs, which were knitted by a friend: a wonderful Health Visitor who is recovering from a severe case of C-19.

This strange and wonderful scheme has 2 aims: to raise awareness of the vital importance of skilled help and support for new families who are establishing breastfeeding and to raise funds for 2 charities who exist for this very reason.
If lockdown has been cruel to your household finances, please DO NOT DONATE. Instead, perhaps you could help Andy's project by sharing info about it with your friends and family. If, however, you do feel able to donate, your support will be very gratefully received.

Here's Andy's fundraising page: https://uk.virginmoneygiving.com/AndyBruce6

And remember, if you ever look out of your window and see a chap on a bike, wearing rainbow knitted boobs, he's doing it for you!

1 Comment

Breastfeeding a toddler or beyond during #lockdown? The best of times and the worst of times.

4/19/2020

14 Comments

An image from the app 'Forest - Stay focused' which can help you set nursing limits.

It’s been a challenging month for many different reasons. But never in the history of natural-term breastfeeding, has any child ever breastfed as much as your nursling. If there were records, they would have been smashed. It’s like your child has analysed the national food distribution network and has decided that YOU need to be a major manufacturer.

Before this whole lockdown business, breastfeeding was an important part of their life, sure, but you felt as though you were on top of the situation.

Now the situation very much feels as though it is on top of you. Very often literally on top of you. With a foot in your ear. Sometimes with a car in their hand. Sometimes twisted to try to see the television at the same time. Sometimes a nanosecond after the last breastfeed.

You’ve mastered the art of the Zoom call with the screen angled so you’re seen above the chin only. You can type at a laptop while breastfeeding and it doesn’t slow you down in the slightest. You can complete a supermarket online shop, peel a potato, colour in a rainbow – all with someone attached at your nipple.

Sometimes you are so grateful that you continued to breastfeed in these uncertain times. Your child is still getting access to the immunological benefits of breastfeeding at a time in history when that has never seemed more sensible. But this is hard. Touched-out is phrase that is sometimes used. Touched-out feels like a distant memory. You don’t feel you have control over your own body.

You are trying so hard to empathise with your child. This must be weird for them. They are stuck inside. No nursery. No wider family. Life feels different and they may not fully understand why. Grown-ups may have anxieties. Something is going on. Breastfeeding is the time when they feel safe and reassured. They can control this world that appears to be out of control. They request a breastfeed and it happens. They feel connected to you and feel they have some influence over their universe. They may also feel bored. Breastfeeding is something to do.

We can be empathic, and we can value natural-term breastfeeding and we can set limits all at the same time.

Breastfeeding an older child does not mean that YOUR feelings matter less. Breastfeeding an older child does not mean that YOU are not permitted to sometimes focus on yourself. You are allowed to feel fed-up. You are allowed to have had enough.

Your child does not want to be parented by a martyr to the cause of breastfeeding. They need a real human with feelings and desires and bodily autonomy.

This is their first intimate relationship. You are teaching them about kindness to others. You are teaching them that the feelings of others matter and sometimes we need to focus on other people ahead of ourselves. You are teaching them that sometimes people need to take a moment, have some space, have a breather. None of that is incompatible with being a good parent. It makes you a better parent.

We sometimes have conversations about ‘nursing manners’ with older children. If they pinch or hit us during feeding, we want to work hard to find strategies to change this. Parents do this because they don’t like getting pinched and hit. ‘Hey, this is not just a breast. This is ME!’ But we also work on this because we want our children to understand that pinching and hitting anyone isn’t kind. Kindness towards everyone begins with these small lessons and talking to a baby who is only a few months old about being gentle and having gentle hands.

Nursing manners extends beyond pinching hands. It means having kindness when the breasts are in the middle of an important meeting or the breasts are tired, or the breasts need to go and get a drink of water for themselves. Even from a young age, it’s OK to talk about the need to wait. Even when time is only beginning to be understood, it’s OK to say, “Do you mind if we just snuggle for a bit or read a book as my breasts/ milkies/ milk-milk need a bit of a rest?” You are teaching a vital lesson about being open with feelings and how those in loving relationships can express vulnerabilities and the need for give-and-take and compromise.

None of this is incompatible with being a breastfeeding advocate and a passionate supporter of natural-term breastfeeding. If you think child-led weaning means you are NEVER allowed to refuse EVER EVER, you may be dissuading others from continuing to breastfeed in the longer term.

Gentle parenting means trying to shape gentle kind people and that happens with modelling and empathy and communication. I was once asked to contribute to a compilation of articles on gentle parenting. I offered a version of my blog on weaning toddlers and pre-schoolers. The editorial team declined as they didn’t feel talking about weaning and restricting breastfeeding fitted with their ethos. Really? I’m not sure they ever got dressed in the morning and purposely chose the shirt with the tinier, more fiddly buttons as it might mean they get a bit more work done that day.

Every time we tell a parent that child-led breastfeeding means no restrictions from the parent at all and the parent must respond to every request for breastfeeding with no limits, we are potentially shutting down older babies breastfeeding for longer. We are perpetuating the myth that breastfeeding means you can’t be a normal person with frustrations and bad days and your own goals and desires.

What might help if you have a Guinness World Record Breaker older nursling at the moment:

1. Just talk to them. Be honest. Say you love breastfeeding, and milkies is special and helps to make them strong and clever but sometimes you need a rest. Just a short one. Milkies will be along again soon. You don’t have to stretch the truth and create some biological excuse. You don’t have to pretend they need time to make more milk. It’s just OK to say how you feel. I have met parents of 3- and 4-year olds who are struggling and will do everything (including putting band-aids on nipples) rather than just try and share how they feel. We can admit to being tired. We can admit to needing to concentrate on something else.

2. Some of this is about them looking to control their world but the world feels out of control. Their speech is developing and their understanding of communication. They ask for a breastfeed and it happens and that’s magic. What else may fulfill that desire? Can they ‘ask for a book’? It’s sometimes said that reading a book together is more like breastfeeding for a toddler than most other activities. If you can’t read at that moment, make a booking waiting room. They can pile up the books they want you to read next, in the order they want them. Or what about a toy waiting room? Or some cards with pictures on that show favourite activities and there is a board where they can stick up the next request?

3. They may be thirsty. Do they have a cup station they can reach and use independently?

4. If you are working from home, they are not used to it. They are not used to you being home and not getting more of your focus. This feels weird. What short activities give you 15-minute bursts of being able to work? In an office, we regularly take short breaks to grab tea, talk to a colleague, even just pick up your phone and scroll. It’s OK for focused work at home to only be in relatively short bursts. Use a timer to show them time passing. The app ‘Forest – stay focused’ allows you to plant a cyber-tree which then gradually grows over the time you have set in advance. The shoot appears, the leaves develop and the tree gradually gets bigger and bigger. At the end of whatever time you have set, you will have a fully grown tree to add to your virtual forest. They can come back and check on your device to see how the tree is growing. Is the tree fully-grown so now it’s time for a breastfeed? Or a chance to read a book? Plant a forest together made from patience.

5. Grant a breastfeed but on your own terms. It can only be ‘count to 10’ (Count slowly or quickly depending on how you are feeling). Or an older child can ‘buy’ a breastfeeding by trading a bracelet or a toy.
“Here are 5 plastic spoons/ coins/ dinosaurs. We’re going to play milkies shop. When you want a breastfeed, you can buy one. But you’ve only got 5 until lunchtime/ dinnertime/ I finish this piece of work.”

It’s amazing how long they will hang onto the last one. They feel in control knowing it’s in reserve. It’s still their choice when to ‘spend’ it.

If you have any other ideas that have worked for you, please feel free to share them in the comments below. You may have a strategy for dealing with a #stayathome nursling that will change someone else’s life.

This is not easy. And it’s OK to need some help. It’s OK to want to set some limits. Parenting a young child at the moment, when we are all stuck at home, is not easy for anyone and just because you are breastfeeding, it doesn’t mean you are immune from that. You don’t have to be the ‘perfect’ parent who constantly puts yourself second. Finding compromises, strategies and sometimes saying, ‘not right now’ is healthy for both of you.

If you are really struggling, you may find resources on breastfeeding aversion and agitation helpful. You can start here: https://www.breastfeedingaversion.com/

My article on weaning older children goes into further detail about setting limits: https://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/weaning-toddler-bob-and-pre-schooler-billie-how-do-you-stop-breastfeeding-an-older-child

14 Comments

Making breastfeeding work when you #StayAtHome

3/28/2020

0 Comments

So, you are home with your new baby. Someone said something to you antenatally about ‘taking time’ as a new family, reducing unnecessary visitors and making a ‘new baby nest’.

And the world has taken it upon itself to make all that happen by arranging a global pandemic.

Slightly over the top perhaps, but here we are. I hope you have everything you need. And don’t be shy about asking neighbours to help you if not.

There are negatives in this situation for so many of us, but there are also some surprising positives. You will not get work harassing you to pop in for a meeting next week. You will not have your mum’s friend Sue ‘popping by’ to make unhelpful remarks about how often your baby is feeding. You will not be distracted by the desire to go to a restaurant on day 6. You can wear pyjamas all day and feel like you are helping humanity.

We always knew partners had a key part to play in helping to make breastfeeding a success (and a partner may be a husband, wife, parent or good friend living with you in isolation) but now you are even more special as access to face-to-face trained breastfeeding support is likely to be limited for all of us.

Breastfeeding has never been more important. It’s the perfect food for your baby and a wonderful medicine – giving pain relief and delivering anti-bodies and ingredients that kill and limit bacteria and viruses while providing calm and reassurance. It can also reduce anxiety for parents too and we know that when someone reaches their breastfeeding goals, it can reduce their risk of mental health problems.

This article is a summary of some key things you need to know to be the best enabler of good breastfeeding in the days and weeks to come.

1. Despite how it may feel, you are not alone.

In most areas, you are being called by your community midwife soon after getting home and if you need to be seen face-to-face, that can still happen. You will get a face-to-face visit within the first few days where your baby will be weighed. Most babies will lose some weight after birth but ideally not more than 10%. If you are ever worried about any aspect of feeding, find help. Don’t wait to see if problems will work themselves out. The breastfeeding support community (lactation consultants, breastfeeding counsellors and peer supporters) are sitting at home too. Calls to the helplines are answered by volunteers who are specifically trained in being able to talk about breastfeeding without being able to see you. It always sounds a bit daft, but we know how to support with positioning and attachment without being in the same room. Try the National Breastfeeding Helpline on 0300 100 0212 (9.30am-9.30pm). There are several other helplines with different hours. You can also contact lactation consultants from across the UK who will use phone and video consultations to support you. Many local breastfeeding drop-ins have moved to being online.

Have a look here for details on how to find different kinds of support: https://abm.me.uk/wp-content/uploads/COVID19.pdf

2. Use technology to your advantage.

Many lactation consultants and local breastfeeding support teams are using remote support like Zoom consultations, WhatsApp chat, Facetime calls and Skype. We can SEE breastfeeding sometimes more effectively than we were able to before. It’s useful for us to check how a baby is swallowing (more on that later). Usually during a breastfeeding assessment, we politely lean over to take a look at the baby on the breast for a few moments. With video, and a moveable camera like a phone or iPad, we can hover 5cms about the baby’s cheek for 10 minutes and no one thinks we are weird.

It’s really useful if you can record some short videos to share with your breastfeeding supporter. Short ones that are less than 30 seconds will be easier to send. Take a video of the feed from different angles including standing a few steps away. We’re looking at how the baby is held, the arms holding them, the chair, the cushions. And close up too – from above and then come around to the side so we can see both of the baby’s cheeks. Stay above for a moment so we can see the baby’s chin moving as they are at the breast. And at the end of the feed, as the baby comes off, what does the shape of the nipple look like?

We will keep these videos securely and respect your privacy. We may suggest that during our conversation, we all watch the videos again together. A bit like you are a professional tennis doubles team and we are your tennis coach watching a replay. We’ll talk about what we notice and how perhaps slight changes can improve things.

3. If breastfeeding is uncomfortable, there are small changes that could make all the difference.

You don’t always have to be trained in breastfeeding support to be able to suggest some changes that could really help. If your partner is in pain, just one comment, just one observation could transform everything and help the baby to get more milk. Breastfeeding isn’t supposed to be painful. A stretching feeling in the first few seconds of early breastfeeding is not the same as a feed that is painful, hurts all the way through and leaves a nipple looking squashed/ pointed/ ridged. If breastfeeding hurts, talk to someone. However, you may also be able to make some suggestions.

Are they moving the breast TO the baby? Almost like they are bottle-feeding with a breast? Perhaps they are leaning forward, pulling the breast out of its natural position to reach the baby? If that’s happening, chances are that it’s shifting inside baby’s mouth once baby is on and bringing the nipple back to rub somewhere it shouldn’t. We talk about BABY TO BREAST. Make sure, if cushions are being used, they are the right height. Check they aren’t leaning forward to get to the cushion or lifting up their breast so there’s space for baby to fit in. This article outlines lots of the common adjustments that can make all the difference: https://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/breastfeeding-is-just-like-golf-a-tiny-adjustment-makes-all-the-difference.

We want the baby to come to the breast CHIN FIRST. The chin is the first thing that makes contact with the breast. We want the baby really close to you. If clothes are bunched up in the way, or baby’s hands are at their chin, they will get less breast in their mouth. And we want their mouth full of breast. If they come to the breast chin first, with the nipple under their nose, they are more likely to tilt back and get a good mouthful.

If I offered you a drink of water now, you’d naturally raise your chin away from your chest to swallow. Try and swallow with your chin pointing down – it’s hard. And it’s also hard to swallow if your neck is twisted. We want a baby’s ear, shoulder and hip to all be pointing in the same direction. Babies don’t like it if they don’t feel anchored and secure and they don’t like it if someone is pushing on the back of their head and holding their head tightly. They want freedom to be able to tilt their head back, so we support their bodies and around their shoulders. Often leaning back helps make breastfeeding more comfortable. Have a look at some of the resources online about biological nurturing or laid-back breastfeeding: http://www.nancymohrbacher.com/breastfeeding-resources-1/2016/12/26/natural-breastfeeding-video

Remind yourself about what an effective latch looks like by watching this video: https://globalhealthmedia.org/portfolio-items/attaching-your-baby-at-the-breast/

Sometimes a few days go past, or weeks, and things change without us even noticing. If breastfeeding has become more uncomfortable, it might be that a baby has got a little heavier and the position you used when baby was tiny now means their weight is pulling them off the breast.

4. Know how to measure how much milk is going in.

It’s true that most new babies are going to be weighed a little less over the coming weeks. Again, if you are really worried, there are people who may be able to support you with this, but we’re not going to be popping to the weighing clinic as we once did. Some families are hiring or buying baby scales to use at home. Sometimes this is valuable, but over-weighing is not always useful and can make you feel more anxious. Talk to someone about how often is sensible for your situation. It’s not a great plan to rely on using normal bathroom scales and trying to weigh yourself and then weigh yourself holding baby. This will often have accuracy problems and we are usually only talking about 100 grams here and there.

Nappies are the key. When a baby is one day old, we’ll see one poo and one pee in 24 hours. On day 2, two poos and two pees. From then on, we’ll see AT LEAST two poos every 24 hours (the size of a £2 coin or bigger). More poo is better and babies taking in lots of milk will do often more than 4. The poo will change in colour. The first day we will see black sticky tarry poo called meconium. As the days go by, the poo gets paler. By day 2-3, often a bit greenish. We don’t want to see black poo any more after day 4, and talk to someone if you do. By day 4-5, we should be seeing pale, mustardy poo. We carry on seeing several poos a day for the next few weeks. Only around 6 weeks does it slow down for some exclusively breastfed babies and their poo rate may start to slow down and they may skip some days. But young babies do not skip days. We need several poos a day to know milk is going in as it should.

With pee, we want 3 pees on day 3. Four pees on day 4. On day 5, five wet nappies. From then on, 6 or more heavy wet nappies in 24 hours. You shouldn’t have to think, “Hmmm, was there a pee?”, the nappy should feel heavy enough that you know. If you aren’t sure, talk to someone.

https://www.nct.org.uk/baby-toddler/nappies-and-poo/newborn-baby-poo-nappies-what-expect

5. Know how to see milk going in.

It’s not only nappies that can tell us a baby is getting milk. We can look at the top end too. I don’t mean a baby is being sick (although that sometimes happens, and if nappies are good and the baby doesn’t seem to mind, and it’s not projectile, that can be OK.)

I’m talking about knowing what a baby swallowing milk looks like. Breastfeeding happens for lots of different reasons. Sometimes babies are there to feel safe, to help them fall asleep, to feel comforted. All that is important and to be valued. Babies are supposed to ‘use us like a dummy’. They have a lot of brain development to do and they are learning important things about trust and comfort. But we don’t want them to only be on the breast to suckle and comfort themselves. It’s good to be able to recognise when milk is definitely going in.

At the start of a feed, a baby will suckle quickly to get the milk flowing. Then they will settle into a suck/swallow pattern where you will be able to hear them swallowing milk. In the first few days, when your milk is still the rich colostrum, you may hear less gulping. But when the milk has begun to transition around day 2-4 and it’s changing to mature milk which is lower in protein, higher in fat and higher in volume, you’ll hear some swallowing at the start of a feed. As the milk gradually gets fattier (which happens gradually as the minutes go by), you may notice they do more sucks for every swallow. But they will still be swallowing. How do you tell when a baby is swallowing?

Have a look at another video from Global Health Media:
https://globalhealthmedia.org/portfolio-items/is-your-baby-getting-enough-milk/?portfolioCats=191%2C94%2C13%2C23%2C65

And this video from Dr Jack Newman:

https://www.breastfeedinginc.ca/really-good-drinking

We’re looking for the chin to come down and a pause in the chin to indicate a swallow. By the way, you can’t always tell how much milk a baby is getting by counting how many minutes they are on the breast. A feed that lasts 30 minutes isn’t necessarily ‘better’ than one that lasts 8 minutes. It’s all about what they are DOING in those minutes.

This breastfeeding assessment tool from UNICEF Baby Friendly explains that an effective breastfeed may be anything from 5 to 40 minutes. There are lots of good ideas about how to check feeding is going well here:

https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/10/mothers_breastfeeding_checklist.pdf

6. Feed often.

New babies feed frequently. You might have been told something about ‘feeding on demand’ and waiting for babies to tell you if they want the breast, but anyone who specialises in breastfeeding will tell you otherwise. SOMETIMES WE HAVE TO TAKE THE LEAD AND MAKE SURE FEEDING HAPPENS.

New babies can be sleepy. They sometimes have jaundice. They sometimes sleep through feeds and their blood sugar levels drop. We may have to be bossy at the start. Being bossy also reduces the risk of getting engorged which happens in the first few days and our breasts are moving from colostrum onto the next stage of milk.

We don’t want a young baby to go longer than 3 hours from the beginning of a feed to the beginning of the next feed. That includes at night too until we are really confident they are putting on weight and doing well. We will need to wake a sleeping baby sometimes. If a baby is sleepy, you might take off layers or tickle them or blow on them. As long as they are attached to the breast, you can also push milk into them using a technique called breast compressions: https://breastfeeding.support/what-is-breast-compression/

And just because we talk about not going longer than 3 hours, that does not mean we are aiming for 3-hour gaps. That really would be a minimum. Healthy babies breastfeeding will often feed a lot more than that. We need to respond to their requests to breastfeed as that helps make sure they get enough milk, they feed calmly and don’t take in more air because they are upset. It also means our milk supply gets the signals it needs. It’s important we don’t try and push babies to ‘go longer’ thinking that will make breastfeeding easier. It can have some serious consequences: https://www.unicef.org.uk/babyfriendly/breastfeeding-the-dangerous-obsession-with-the-infant-feeding-interval/

A baby asking to feed will show you in lots of different ways. They will be a little restless, move their head from side to side, open their mouths and sometimes make murmuring noises. They might suck on anything nearby. Crying is what we call a ‘late stage’ hunger cue. But if you are ever not sure a baby wants to be on the breast, you can’t go wrong by offering. You can’t overfeed a breastfeeding baby. If they aren’t wanting to feed, they may suckle instead. As mentioned before, breastfeeding has a lot of value that goes far beyond feeding.

7. Expect babies to want to be close

We are primates and like other primate parents, our babies want to be close to us. When they are close (and skin-to-skin isn’t just for straight after the birth), they are calmer. Their heart rate and respiratory rate is optimised, and it helps us to notice when they are asking to breastfeed. Babies like being held and you can’t ‘spoil’ a baby. They might like being held in a sling, which can also be helpful if you have other children to look after. They want to be close at night too. About 70-80% of breastfeeding families share their sleeping space with a new baby and it’s important to know how to do that safely. When we don’t prepare and fall asleep accidently when holding a baby, there is far greater risk. The BASIS website has guidance around safe sleep for babies: https://www.basisonline.org.uk/

8. If a baby isn’t feeding at the breast…

…You’ll want to get some help. You can call a midwife or a health visitor (once you have been discharged by the midwife). You can call a helpline or sometimes you may have been given a number to call at the hospital. In the meantime, there are ways to still get milk into your baby. You can hand express (take milk out of the breast by hand): https://med.stanford.edu/newborns/professional-education/breastfeeding/hand-expressing-milk.html
And you can give milk to the baby in different ways. Cup-feeding using something like an egg cup or small plastic medicine cup is one option (Do watch a video as it’s not pouring milk into a baby’s mouth and needs some care): https://breastfeeding.support/cup-feeding-newborn/

You can also spoon feed milk into a baby. Even getting them to suck on a milky finger may mean they take a little milk which may help them to breastfeed.

No one is expecting you to know everything. You don’t have to solve every problem or know every answer. There are lots of people who are here to help you. But there are some keys principles that will help you to feel more confident and help breastfeeding to go well: know that breastfeeding shouldn’t be painful, know how to tell if a baby is getting milk, know that we respond to baby’s requests for feeds but sometimes we may need to nudge, know where to get help.

If a parent breastfeeding does get unwell, continuing to breastfeed is ideal. Your baby will benefit from the anti-viral antibodies that are tailor-made to fight this specific virus and delivered in the milk. There is no evidence that the virus is carried in breastmilk. Some are choosing to express some extra milk and have a store of some milk in the freezer as a protection in case they feel very unwell. For most people, their symptoms will be mild and they can breastfeed as normal while being more careful around hygiene. You can read more here: https://www.breastfeedingnetwork.org.uk/coronavirus/

0 Comments

<<Previous

"Don't offer, don't refuse."

Breastfeeding after 12 months and dental decay

Flat nipples

Negotiating a 2021 family Christmas

Newborn breast refusal: why didn't my baby get the memo?

Lactation cookery or lactation crookery? Why I’m worried about lactation cookies.

Toddler twiddling

35 activities for children during #StayAtHome

Breastfeeding a toddler or beyond during #lockdown? The best of times and the worst of times.

Making breastfeeding work when you #StayAtHome

Author:
Emma Pickett IBCLC

Find me on twitter: @makesmilk

Find me on pinterest:
https://www.pinterest.com/makesmilk/youve-got-it-in-you-a-positive-guide-to-breastfeed/

Categories

Archives

Author:Emma Pickett IBCLCFind me on twitter: @makesmilkFind me on pinterest: https://www.pinterest.com/makesmilk/youve-got-it-in-you-a-positive-guide-to-breastfeed/

Categories

Archives

Author:
Emma Pickett IBCLC

Find me on twitter: @makesmilk

Find me on pinterest:
https://www.pinterest.com/makesmilk/youve-got-it-in-you-a-positive-guide-to-breastfeed/