Breast refusal can be scary and we start with lots of gentle questions. She’s worried. Plus she’s upset that family members are telling her she’s given breastfeeding a good go and now surely it’s time for bottle-feeding.
It turns out there is one simple problem and it’s not breast refusal. This mother was told that feeds at the breast ‘should’ last a minimum of twenty minutes. She was told that if the baby didn’t feed for twenty minutes, her baby wouldn’t get enough ‘hindmilk’ and there would be big problems. She has spent the last hundred or so feeds thinking that something is horribly wrong and her baby is at risk. Many many minutes of anxiety and fear for no reason.
Breast feeds have been a battle because her baby is efficiently feeding for around 7-8 minutes (this is the feeding ‘a little’) and then baby and mother have been engaging in a wrestling match as she desperately tries to get to the magic twenty minutes and the baby is trying his level best to indicate this isn’t what he wants. He’s not breast refusing. He’s saying, in the only way he knows how, “For Pete’s sake, mum, I’m fine!”
The breastfeeding assessment tool from UNICEF Baby Friendly doesn’t talk about this 20 minutes minimum (https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/breastfeeding-assessment-tools/ ). They say baby, “will generally feed for between 5 and 40 minutes and will come off the breast spontaneously”. This is true for an assessment being carried out by a midwife, a health visitor or anyone else. They might be looking at a newborn or an 8-week-old baby or an 8-month-old baby.
The myth of ‘at least 20 minutes on each side’ exists in many places. Sometimes it’s randomly 30 minutes or 15. I met someone who was once told 18 minutes which was a new one. It’s not necessarily in the baby books you might expect. They will often talk about being guided by the baby. Although it’s interesting how your brain might not absorb the reality of ‘being guided by the baby’ when elsewhere in the same book you’ve been told there’s a 20-30 minute average. Those are the numbers that often seem to stick in the brain of a brand-new parent. We like something we can grab onto.
It’s very hard not to believe that more minutes is ‘better’. SURELY more minutes means better milk and better quality milk. SURELY the short feeds are poorer and worth less. So logically when a baby who once went 15-20 minutes reduces to 7-8 minutes this feels like a deterioration and means bad things.
It’s a common call to the breastfeeding helplines that a baby seems to have suddenly reduced the length of their feeds. Something seems to kick in after a few weeks for many babies. It might be that tongues and cheeks and jaws are more developed and more skilled. It might be that babies are less sleepy and keen to get back to the interesting stuff of absorbing the world. It might be that our supply has increased and our milk ejection reflex is faster. And the same baby might feed for 5 minutes and then later 45 minutes, in the same day, just to keep us really confused.
It feels uncomfortable when it’s been drilled into you from the very beginning that there’s this special stuff called ‘hindmilk’ and it can only be reached after X (20, 30, 18) minutes. If your baby only feeds for 5 or 7 or 10, they will only be getting the ‘foremilk’? Won’t they?
Like most lactation consultants, I often say things like, “We used to talk about foremilk and hindmilk but actually…” Or, “ those terms aren’t very helpful.” Or, “there’s only milk.” Or, “any change in fat content happens gradually.”
When a breast is at full storage capacity, and the alveoli in the lobes are stretched to their maximum and a milk ejection reflex happens, teeny myoepithelial cells will squeeze the alveoli in response to the oxytocin hormone and milk will start to flood through the ducts down towards the nipple. That first flood is going to be high in water content (and lactose and other important things). It still gives energy, it’s still valuable and important, but the fat molecules won’t be maximised in that first flood of letdown. Fat is sticky and it’s stuck to the walls of the alveoli and to other fat molecules. It takes a moment for them to be dislodged and start to enter the milk and do their journey down through the ducts.
The idea that the fat won’t arrive for 5 or 10 or 15 minutes just isn’t evidence-based information. One fat molecule may break away immediately. And its friends will gradually find their way over the next few minutes. The proportion of fat will increase gradually and steadily. There is no ‘foremilk’ or ‘hindmilk’. There is just milk that gradually changes. And first milk that was lower in fat but rich in carbohydrates is not worth less.
There is such a huge amount of variation between breasts. That mum over there has 20 milk ducts. She has a forceful letdown reflex and when she gets a milk ejection reflex there are 4 visible sprays of milk that travel 5-10cm away from her body. That other mum has 6 milk ducts. Her letdown gently happens and there are 2 visible duct openings on her nipple and nothing that could be described as a spray, just some drips. Both are normal. And in both cases, their babies are doing just fine.
Perhaps one baby is buzzing with energy and gulps away loudly. Another baby is sleepier and pauses and swallowing seems more gradual.
One exclusive pumper fills a 100mls bottle in 6 minutes and has to change to a new one. Another exclusive pumper takes 15 minutes to get 40mls and has to use lots of hands on pumping and massage techniques.
How can it be possibly true that in all these situations, it’s taking 10 minutes for some theoretical stage to be reached in milk quality?
In one case, maximum fat levels may be reached in 6 minutes, in another 16 minutes and in another 26 minutes. If we say that ‘everyone must feed for 15 minutes on one side’, bad things will happen. Some babies will be in a constant battle where they are told they should be feeding longer, and they really don’t want to. Feeds will become miserable for both a mum and a baby. Other babies will be removed from the breast before they were ready to be moved and miss out on milk they wanted and needed.
We’ve been saying, ‘watch the baby, not the clock’ for a long time now. It’s rare these days to meet a parent who tries to feed on a three-hourly schedule (and very very rare to meet someone trying for four hours). Parents are getting the responsive feeding message and understand that cluster feeding might be normal and it’s normal for there to be variation as babies come to the breast for a meal or a drink or some connection.
But these same parents who understand responsive feeding are still sometimes focusing on minutes in a way that doesn’t always make sense. They KNOW deep down that breastfeeding is more than just a milk delivery system. They know it might sometimes be a baby who is thirsty on a warm day, hungry, unsettled or asking for comfort. They may even know that their milk production varies during the day and sometimes flow appears to be faster or slower and milk can change. But when their app on their phone counts minutes, a different bit of the brain seems to swing into gear.
I’ve had conversations where someone has told me that a 40-minute feed is ‘better’ than a 15 minute one. I’ve had conversations where a feed was unusually long because there was a latching issue and once that was corrected, the feed became more efficient and effective. But that was disconcerting for parents who always believed long means more milk and short means less.
And what about when the breast wasn’t at full storage capacity to start with? The foremilk/ hindmilk description becomes even more unhelpful when we’re talking about a normal day of breastfeeding where a baby might cluster feed or return to the breast after only 40 minutes or an hour. It might be that there is more fat in the first mouthful of a breastfeed than there was in the last mouthful of the day before.
You can drive yourself up the wall as a new parent trying to work out the science of the minutes of breastfeeding. Should I go back on the side he was feeding from half an hour ago? Will it have reset to ‘unfatty’ milk yet? What about if 45 minutes have passed, NOW should I offer the other side? What about if that last feed was really quick? Should I then go back to that side and ‘finish it’?
So I would try not to focus on this sort of detail. You are not going to be able to fine tune things to this degree. And you will also find that almost everyone you ask about what to do will give you a completely different answer – which is a clue that there isn’t one answer.
Instead, try and give breasts an even go of things (unless you need to spend more time on one breast for a specific reason). They should get an equal chance to be the first breast and get the enthusiasm of a hungry baby. They should get a roughly equal chance during the day. And if you returned to a breast when you ‘shouldn’t have’, the world is still going to turn and you will be OK. When we relax, we help oxytocin to do its thing. When we focus on 11 minutes instead of 9 and pressing buttons on an app, that doesn’t feel very oxytocin-friendly.
It’s helpful to understand what swallowing looks like so you can understand when milk is being transferred. Dr Jack Newman has a video called ‘really good drinking’ (https://www.youtube.com/watch?v=4aXY1fy75Is) and it’s useful to watch how the baby’s chin comes down with that deep drop. There’s a pause as the baby’s mouth fills with milk before they do another swallow. It’s not a flutter or a nibble.
Sometimes babies do take a rest. They may sometimes do a little flutter as they fall asleep, or wait for a new letdown reflex, but we would want to see some of that deep chin movement. You would expect to hear swallowing once the milk has transitioned from colostrum and milk has come in. You may not hear it all the way through a feed, but some audible swallowing is a marker for good feeding.
A baby that does that kind of drinking and comes off the breast by themselves happily (they might have fallen into a contented deep sleep) and the nipple is a rounded shape without being squished is in a good place. That might take 5 minutes or 7 minutes or 17 minutes. If it takes 57 minutes every time, I might suggest you get someone trained in breastfeeding just to check everything is OK.
Having said that, if you spend every feed with a fixed stare at your baby’s chin assessing swallows, I’m going to bet you’ll just move to count swallows instead of minutes. And there will be a ‘tap this button on your app every time you see a swallow’ along in just a moment. It’s about finding a balance.
What’s not OK is when a very young or sleepy baby is having a short feed without this kind of active feeding. A baby that falls asleep almost immediately and goes straight to the nibbly flutter needs some help finding his oomph. This kind of five minute feed is not the ideal. Babies might close their eyes and appear to be asleep when they breastfeed. Breastfeeding involves involuntary reflexes rather than a conscious effort. But there’s a difference between a baby closing their eyes and still doing those deep chin movements for several minutes and a baby that does an unenthusiastic flutter when you fiddle with their feet but not much more. There are people who can help you if you aren’t sure. We can talk about latching and breast compressions and helping a baby to get what they need. The answer is unlikely to be ‘more minutes’ as the key bit is what is going on in those minutes.
It's about looking at the big picture. Are you happy about what a baby’s nappies should look like in the first few days and weeks: https://www.nct.org.uk/baby-toddler/nappies-and-poo/newborn-baby-poo-nappies-what-expect
Are you happy about how your baby’s red book can be a tool that tells you how things are going (but it isn’t the only answer)? https://www.nhs.uk/conditions/pregnancy-and-baby/baby-weight-and-height/
Is counting the minutes really helping you? Are you looking at an app when you could be looking at a chin? If you start finding yourself thinking, “Yay, that was an 18-minute feed instead of a 12-minute feed, Woop!”. Pause. Will you feel that way when they are two and they take 16 minutes to eat pasta instead of 11? I know it’s different when they are breastfeeding because we can’t see what they are eating and it’s understandable that we are looking for proof. But counting minutes won’t give you that.
Know what swallowing looks like and over time you’ll relax about that too. You’ll develop a faith that things are going well because the evidence points that way. You won’t stare at their chin forever, and you’ll move onto eating your own snacks and enjoying a boxset.
If someone is saying, “she should be feeding for at least 20 minutes,” ask why? We know that it’s how you spend those minutes that really counts. You can drink beer through a tiny thin straw or be like a college fraternity brother on a challenge downing a pint. Breastfeeding is about what’s happening in those minutes and how you feel about them.
Don’t let any app tell you different.