Some how, some where, new mothers got the message that the gap between when a baby stops a breastfeed and the time they start to need another one matters a very very great deal.  24 hours a day.

It seems to matter beyond all logic and reason. They see this magic number – 90 minutes, 2 hours, 3 hours – as a measure of something sacred.

And it’s crap.

There are mums sitting at home, relaxing and nesting with their gorgeous new baby. There’s a disk from a box set in the DVD player, a cup of tea on the go, a recent chat with a friend. Breastfeeding is going well.  Weight gain is fine.  Baby is content. But when baby shows hunger cues after only 40 minutes instead of the hoped for 1hr 30 minutes, their heart sinks and they feel a sense something is fundamentally wrong. They aren’t ‘doing it right’. Their friend’s baby ‘goes longer’. Doubts creep in.

As adults, we grab a cup of tea, a glass of water, a sweet, a snack. We respond to our personal cues and we’re flexible depending on time of day, the temperature, our  mood, our energy levels. Many go to bed with a glass of water or sip from a bottle throughout the day. I don’t know any adults that look at their watch and say, ‘Only 30 minutes till my next sip of water or mint!  Not long now’. But yet we expect teeny growing babies to be governed by this artificial notion of time.

I spoke to a new mother last week who was perfectly HAPPY with her feeding routine but wondered if she should start to stretch her baby’s intervals because ‘that’s what you do’. When I explained that it wasn’t necessarily, she said she was more than happy to go on as she was.

Where do these ideas come from? They don’t come from anyone with any breastfeeding education, nor antenatal classes with breastfeeding professionals, nor books written by those trained to support breastfeeding.

They come from popular baby care books and relatives and peers.

They seem to come from a fundamental misunderstanding of the science of breastfeeding and breastmilk production.  Often they come from mid-20th century ideas based around the norms of formula-feeding and pseudo-science. And that’s all incredibly dangerous.

There are still people out there, surrounded by breastfeeding, who believe that a baby who feeds after 4 hours rather than 3 hours will 'take more milk'. There are people who believe that you need to wait and hold a baby off to let your breasts ‘refill’. There are people who believe that when a baby does want to return to the breast after only an hour that must reflect a ‘problem’ and perhaps the mother even has a supply issue.

It’s scary and extremely frustrating that basic messages about how milk production works don’t reach the people who need them.

So what is normal? Well, how long have you got? Because there’s a lot of normal.  A newborn should feed a minimum of 8-12 times in 24 hours. That means some might be going every 3 hours and others will be feeding more frequently than 2 hourly. Some babies may feed every 10 minutes every hour. Some may feed for 10 minutes every 2 hours. Some may feed for 40 minutes every 2 hours. For periods in the day, a younger baby will often cluster feed and not be happy away from the breast for any longer than a few minutes at a time. This natural cluster feeding may dominate an evening.

A very common call to the National Helpline goes like this: “My baby used to sleep in the evenings and now he’s awake for 3-4 hours. The only thing that seems to settle him is the breast. I feel like I must not have enough milk as he’s on there for ages. Surely there can’t be anything there.” As the baby swaps from breast to breast, getting small quantities of very high fat content milk and decompressing at the end of a long day, they know exactly what they are doing.

And soon their patterns will change again. Some babies will start to longer intervals in the day as the months go by. But NOT all will.

One of the most popular baby care books (which I better not name) gives a strong direction that while frequent feeding might be occasionally acceptable during growth spurts, this holy cow of the interval between feeds matters greatly.  A 3 month old baby might be going 3 hourly intervals but if this isn’t increasing at 4 months, then oh dear. This same writer believes a woman can measure her milk supply by doing a yield test and using a pump to extract milk which apparently will be the equivalent amount to what her baby extracts during a feed using an entirely different process. What this woman doesn’t know about breastfeeding could fill an encyclopaedia.

What I find particularly dangerous about her message that longer intervals are ‘better’ and ‘correct’, is that is means new mothers doubt their milk supply with absolutely no justification. And I know from having spent time on the message boards associated with this writer, many mothers will end up supplementing with formula to try and reach these magic numbers of minutes.

Why?

Babies are no longer being exclusively breastfed and parents are not following Department of Health recommendations because of incorrect information in a baby care book.

There are parents who choose to use formula for a whole host of complex reasons. Some do so happily and some do so miserably. But to do so, merely because you have read a lie in a book, seems tragic to me.

Our knowledge about breasts has been transformed over the last 20 years. Much of the pioneering work has been done in Australia by scientists like Professor Peter Hartmann and Dr. Donna Geddes, Steven Daly and their teams.

We used to think most women had a pretty similar number of milk ducts but the ultrasound research revealed there were less than previously thought and the range was big. One woman had 4 ducts at the nipple. One had 18.

But it’s the findings about breast storage capacity that we need to talk about here. When a baby feeds, some milk is manufactured during the feed itself and some is taken from milk that has been stored in the breasts between feeds.

Ultrasound revealed that a mother’s storage capacity cannot be guessed from breast size. Breast size is obviously not just about glandular tissue. The range in breast storage capacity was huge.

One mother was able to store about 2.6oz per breast.  Another woman stored more than 20oz. That's not a typo.

Women with a smaller breast storage capacity had a healthy milk production over a 24 hr period and their babies had good weight gain. But their babies might need to feed more frequently to access this healthy milk production.


Is this a mother with a supply problem?

No, it is not.

Her baby may continue to feed 2 hourly or even more frequently for a few months during the day, cluster feed at certain points and perhaps continue to wake a couple of times hungry at night.  Her friend’s baby may settle into a pattern of feeding less frequently over a 24 hour period. This friend’s baby may not be receiving more milk overall.

When breasts are fuller, milk production slows. When breasts are emptier, we make more milk. When babies feed more frequently and from emptier breasts, they receive milk with a higher fat content. Frequent feeding has value. And as human milk has a fat content of around 3-5% compared to some mammals who have a fat content of 40% +, it seems pretty clear we’re designed as a species to need feeding more frequently.

But let’s imagine the mother with the smaller breast storage capacity has read this baby care book. She might become distressed that her baby still wants to feed 2 hourly. She might even try and stretch the interval between feeds in the mistaken belief this will increase her baby’s intake. And in doing so, her breasts spend longer at full storage capacity and their milk production slows and her breasts receive the signal to decrease milk supply.

So in her attempt to stretch between feeds as the advice she is reading suggests she does, she may actually be decreasing her overall milk production in 24 hours and be doing some actual harm.

So what should we suggest to this mum who never seems to be able to stretch her baby to longer intervals in the ways that her friends seem able?

First off, we should congratulate her for responding to her baby’s cues. Thankfully she knew not to try and impose some routine early on and therefore her milk supply is at its maximum capacity. Let’s check breastfeeding is otherwise going well:  that feeds are comfortable for her, baby does settle for periods of contentment after a feed (though it may only be an hour or even less, rather than 3), weight gain and nappies are fine and latching and positioning is at maximum efficiency. If all this is true, and never reaching a magic ‘interval’ is her only concern, then we need to make sure she knows as much as possible about how milk production works. It is possible she is one of the mothers who has a minimal breast storage capacity and she will need to feed more in 24 hours to maximise the volume of milk her baby receives. And there might be nothing she can do about that. What happens next is about acceptance and support and attitude.

She has to keep that up for ideally around 6 months if her baby is going to get the full benefits of exclusive breastfeeding. She might need greater support with feeding outside the home – perhaps learning how to feed in a sling or experiment with different positions for different environments. It’s possible she may be woken at night more than her friend with the longer intervals – though we would expect night time intervals to be longer and for her to get a block of longer rest. She may benefit from support on safe bed-sharing practices.

And it is just a matter of months. After solids have been established, patterns will change. It’s surprising what we can cope with for just a few months. We have jars of pickle in our fridge significantly older than that. We may even have toothbrushes that are around that long. In terms of an adult lifetime, it’s a blink of an eye.

What won’t help these mothers is the relentless message that they just need to stretch their baby a little more. That if they leave him to cry for 15 minutes, magically he will take more milk and life will change. That just isn’t what science tells us is true for all women.

Of course breastfeeding isn’t just about milk anyway. Apparently there are people who think that a baby comes to a breast primarily to get milk but I’ve not met a parent of a baby who thinks that’s true. Just as we don’t measure our sips of water, sweets and snacks, we also don’t measure every time our family smiles warmly at us, communicates with us, looks for comfort, hugs us, checks in, helps us to feel safe. No smart phone app can measure all the complexities of our relationship with our baby and all the things that responsive feeding can do. You are trying to count and measure love. That's not going to achieve much other than a flat phone battery. And you could miss out on some magic that you can't go back and live again.

And I’m talking about myself here, by the way. My children under 6 months never went longer than 2 hours between feeds in the day and not much longer at night. My red record books records me feeding at 3 months every 90 minutes or so. So I learnt to feed while babywearing. I went to friendly groups and friendly places and met up with people at home. I read about safe co-sleeping practices which I know beyond a shadow of a doubt saved my bacon. And thankfully, I never felt anything was ‘wrong’. I just trusted my body. I trusted my baby and we worked as a beautiful team. I sat at home on the sofa and fed relatively frequently, enjoyed my box sets and my healthy and not-so-healthy snacks and that was OK. It really wasn’t for long. But the benefits of exclusive breastfeeding will be.

Why should a watch or clock tell me how to be a mother? I’d rather pay attention to my baby.

 

Sources:

Anatomy of the lactating human breast redefined with ultrasound imaging. DT Ramsay, JC Kent, RA Hartmann, and PE Hartman. 2005.

The magic number and long-term milk production.  Nancy Mohrbacher IBCLC

Studies on Human Lactation: Development of the computerized breast measurement system.  D.B Cox, R.A Owens, Peter E. Hartmann

Originally written 2011. Updated July 2016.

I’ve got a lot to say about breastfeeding and parenting. Some might be new but a lot of it will be old. In fact that should be spelt as ooooooold. Stone- age old. Pre-stone age old. But it has to said anyway. If I sneak it out during the X-factor live show maybe not many people will notice.

We need  the science bit.

Mammals comfortably split into 4 groups in terms of their parenting styles. These parenting styles are directly reflected in the constitution of their milk – fat and protein and carbohydrate levels vary dramatically among mammals. Guinea pig:  fat levels can be 46%. Human milk: pretty stable at  less than 5%.

We’ve got the cache mammals who hide their young away somewhere hopefully inaccessible from hungry coyotes and potter off and look for food and presumably do other useful things for up to 12 hours. These mammals need to have milk rich in fat and protein and these youngsters are left to fend for themselves. And at birth, the newborn mammal is relatively mature. Think rabbit. You don’t see rabbits hitching a ride on mum’s back. But – hang on - what’s a rabbit going off and doing for up to 12 hours at a time? Let’s not dwell on that bit. They’re cache mammals.

I think you can imagine where I’m going with this.

Nest animals will feed about every 4 hours (Wolves, dogs, cats). The more immature young will huddle in their group and need to feed more frequently than a cache mammal.

Follow animals feed about every 2 hours. Cows and Giraffes are again reasonably mature at birth. They are capable of keeping up.

And carry animals feed virtually continually. Feeds will often be clustered and intervals might be quite short. Fat content of milk is extremely low (Apes, marsupials, us).

In terms of maturity, these carry newborns are as about as dependent as it gets. Without close bodily contact with parents, respiration rate and oxygenation rate, heart rate, growth, stress hormone levels – this stuff doesn’t start to look good.

When it comes to the maturity thing, we are spectacularly rubbish. And you can blame a battle we’ve been fighting for hundreds of thousands of years:  Human pelvis shape Vs. Human brain size. Our brain is enormous and our skull reflects that. But – oooops – we seem to like walking upright and that produces a problem. We need a neat upturned pelvis that holds our weight and gives us nice straight legs. Any more extreme than what we currently have would not be ideal for the easiest birth experience. So nature holds back a bit and we might give birth to a relatively huge-brained baby but brain development is still nothing compared to what it will be. The brain is still barely only a quarter of its adult size. By aged 2, it’s about 80% of its adult size. We do a heck of a lot of our development outside the womb.

Just as little squirmy pink kangaroos are born and wriggle into their mother’s pouch and stay put for as long as they can get away with, so our newborns need us profoundly.

No, this doesn’t mean they need a nutrition fix and then get wrapped up and put back in their moses basket across the room again for several hours. You’ll have caught the bit where we’re not wolves or wild cats.

And nor should we be pulling our hair out if they’re not sleeping through the night for a 12 hour stint at 2 months. Not rabbits either.

You can read more about this if you look into the work of Dr Nils Bergman who has been pioneering Kangaroo Mother Care in South Africa. In his eyes, close contact with baby and frequently offering the breast isn’t about the care of premature or unwell babies. It isn’t some freaky hippy option preferred by the muesli-knitters. It’s just science and it’s who we are as a species. If it makes you sad, by all means try something new and try and find something that works for your family. A lactation consultant can help you try and tweak your baby’s routine.  And yes, constant feeding and unsettled behaviour might suggest a problem that needs addressing.

But know that frequent feeding and a baby ‘that just won’t go down’ is the norm. The baby that feeds and settles and but wakes and becomes unhappy when placed on a cold unhuman surface is the norm. Put clocks away and tap into those millions of years of evolution. Trust that we’ve got to where we are as a species because baby’s exhibit useful cues and we respond. Babies grow with milk and love. And it works.

This message is at the heart of a lot of what we need to talk about when it comes to parenting.

We need to know how things went pear-shaped in the mid to late 20th century and why our breastfeeding rates reached an ALL-TIME low as a species when we tried to impose artificially- constructed ideas onto our biological norm.

We need to know how many of the most popular babycare books on the market today are STILL informed by these 20th century ideas – that were just a blip on the landscape of human society historically and globally.

And there are parents out there right now who think a baby that longs to be in their arms is some kind of personal failing. Phrases like ‘spoiling a baby’, ‘rods for our back’, ‘show them who’s boss’ come from this unnatural blip. Our parents and grandparents embraced the mid-20th century blip and sometimes need desperately to see a validation of their own parenting choices in the decisions that we make. It doesn't make for easy family relationships when we say, "actually we don't feel wearing my baby in a sling or feeding more than 4 hourly is 'spoiling my baby', thanks gran."

New mums who worry that their baby still feeds 2 hourly most of the time at 3 months and that this means something is ‘wrong’ need to know the science of breastmilk and breasts. There are babycare books with sales booming who fundamentally misunderstand how breastmilk storage capacity might impact a mother’s intervals between feeds and have ignored research from the last 2 decades. There are mothers out there who genuinely think they should be aiming for 4 hourly intervals.

More on how biology informs our natural feeding intervals and this new research in the next post.

To be continued.

I worked with a new family for the second time today. I won't go into too much detail but things aren't going well with breastfeeding and mum is in a lot of discomfort.

As I left them today with plans to see them next week, I knew absolutely that the dad was holding them all together. I am not doubting the determination or commitment of that brand new mother recovering from her difficult birth and finding life was tough but that father - of only a few days - had precisely the strength that his new family needed.

He sat quietly while she described her experiences and her perception of what was going wrong, he gently prompted and corrected when it was appropriate to do so and all the time he gave off this force that said, "I know we can do this. I know this is the best thing. We are going to make this work."  He actually said out loud, "We believe in this."


At one point mum was concerned she might not be able to go on and he said softly, "the low point was two nights ago. You've come really far since then. Things are getting better" and he explained how. And she said, "Yeah, you're right" and calmed immediately.

He praised her without being sappy. He took the baby to calm him at just the right moments. He listened carefully to what was discussed because he knew he was part of this breastfeeding thing too.

He knew that in the middle of the night, when she felt she just couldn't cope, it mattered that he'd paid attention to the right positioning and latching. Not least because sometimes it really helps to have that second pair of eyes looking from a different angle and observing whole body position.


Let's just assume for practical purposes that this bloke must be a prat in other ways as no one could be that perfect - however he absolutely knew how to be a breastfeeding dad.


And I see a lot of dads like that.

It's surprisingly often that it's dad who calls the National Breastfeeding Helpline. It's clear something wasn't going right and for whatever reason mum couldn't face making that call. So dad does and almost always manages to get mum on the phone in the end.

And it's dads who research where the breastfeeding groups are, phone the lactation consultants, get the troops lined up when things aren't going well. They give mum the space she needs and over and over again manage to manouver the support just when it's needed. Yes, sure, some of that is because men like to try and solve problems. They see a difficulty and want to fix it in the face of feeling somewhat helpless. But these same 'helpless men' come to consultations and express their worries while empowering and supporting their wives at the same time. It's a subtle and impressive skill. Especially when you're sleep-deprived.


Dads use some of that diplomacy even when things are going well with breastfeeding. Most new parents today weren't breastfed themselves as infants in the 1970s and 1980s. We are the generation of the formula-feeding grannies. Some of those older women become awesome champions of breastfeeding and some struggle to witness something they don't understand. The dads are the knights at the gatehouse - letting through only the right support. They act as the barrier between new mum and mother-in-law who might not know when to step back. They make sure that the new mum and baby can make the nest they need to.

My own husband, who is a chump in about half a dozen different ways, was one of these champions of breastfeeding. It was something he knew nothing about it. But he trusted me. Not for a moment did he doubt my instincts or my drive to try and get this right. When things weren't always straight-forward, he was able to help me find solutions without ever leaving me feeling disempowered. He knew nothing of breastfeeding through pregnancy or feeding older children but he trusted me. He never questioned me or doubted me. He knew exactly when to step in and step back. And it's something I can never thank him enough for. I know it was largely down to his support that I felt able to train as a breastfeeding counsellor and then qualify eventually as a lactation consultant.


And I know that in a few years time, the mother I supported today will feel the same way about her husband.

Most mums won't end their breastfeeding careers as lactation consultants but that same feeling of support will get them through their own challenges. 

Breastfeeding dads might be good at nappies and burping and baths and making sandwiches and passing the remote control but that's a tiny slice of what they can do. They can provide a bedrock where a new mother learns how she wants to be a new mother and where breastfeeding can flourish.

 

In one of my voluntary roles, I am sometimes asked by national and local media to comment on breastfeeding issues. Today I was asked to comment on whether businesses on Kent should offer more breastfeeding facilities to new parents. In the past year, I have spoken on London radio about breastfeeding in public and been asked to give several comments to newspapers.  Breastfeeding in public  is an issue that never seems to go away. Largely because of the ignorance of businesses and services who have yet to update their employees on the ways mothers and babies are protected to breastfeed in public by law. It must be a constant embarrassment for well-know High Street names to have to apologise for the stupidity of people working in their branches up and down the country. But it continues to be necessary.

Mothers and Babies are not allowed to be discriminated against on the grounds of breastfeeding. Their access to businesses and services is not allowed to be restricted. It's not complicated. It really isn't.

The vast majority of the British public don't wrinkle an eyebrow when a baby is breastfed out of the home. But it's the small minority who grab the headlines and give new mothers the wrong impression they will face discrimination. In my 7 years of breastfeeding, I have fed all around the world - on planes ,trains, mountain-sides, cafes, doorsteps, bus stops - and not ONCE have I ever received a negative comment or glance or been asked to stop. The response has either been warm and supportive or indifferent.

Some mums find breastfeeding in public uncomfortable whether or not they might have to deal with an unfriendly comment. They may be struggling with latch and positioning, be feeding an older wriggly child, or feel self-conscious about any glimpses of their post-partum body they might flash to others. For these mums, the offer of a feeding room can make all the difference. It's really not hard for a business to provide one simple room with the right kind of chair and a door. It doesn't need fancy Winnie the Pooh murals or even nappy changing facilities (toilets work for that). A small cafe or business almost always has an office with a chair somewhere even if a separate room cannot be created. We don't mind a bit of stock sitting in the corner of the room and we don't need it fancy. Just clean and the space to sit down. All businesses need is a warm smile and a bit of imagination and THEY will benefit.

To put it simply, mothers have money to spend. We are a powerful consumer force. The Guardian reported this week that the average family spend £5,213 during the baby's first 12 months. This is a vulnerable time for the British High Street. With a tiny bit of effort - the purchase of a couple of Ikea chairs and a bit of paint - that £5,213 is there for the taking. If retailers fail to use a bit of imagination, fail to educate their workforce about the legal rights of mothers and babies, THEY will lose out. Because online shopping with a cup of tea, bit of daytime telly and baby snoozing nearby is an attractive proposition. The postman brings the parcel and noone has to faff around looking for somewhere comfortable to breastfeed.

Breastfeeding rates continue to rise. If UK retailers and businesses don't understand how to harness this powerful consumer market, they will be the ones to suffer.

This link takes you to the professional code of conduct for International Board Certified Lactation Consultants.
http://iblce.org/upload/downloads/CodeOfProfessionalConduct.pdf