Here's a conversation starter that can be used with any age group. Can you find all the babies in this picture? Which ones are feeding? Which ones were feeding 10 minutes before? Breastfeeding happens all around us and often we don't even notice when it does.
A new mum is asking for help. Her 8-week-old baby is refusing the breast and every feed is turning into a battle. She can get him to feed ‘a little’ and nappies seem OK for the moment but she’s worried that her supply will soon decrease and he’s going to have weight gain problems.
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.
A breast-shaped void: where are the breasts in the new sex /relationships/ health education curriculum?
After a long wait and a thorough consultation with more than 11,000 responses, the Department for Education released its updated guidance for Relationships, Sex and Health education a few weeks ago. From 2020, relationships education is compulsory in all primary schools in England and sex and relationships education is compulsory in all secondary schools.
As the chair of the Association of Breastfeeding Mothers and someone who writes about breasts for parents and young people, I predictably jumped on my computer minutes after its announcement and searched the fifty-page document for the word ‘breast’. There are zero responses.
While menstruation gets 13, and even gets its own sub-heading.
The PSHE Association scheme of work is recommended as a resource to be used in schools. Let’s check there. A scheme of work that covers 5-to-18 year olds. Anything about breast development, breast function?
There are three mentions of the word breast: two are about breast self-examination. Girls are taught about when their breasts are dangerous and pathological, but not when they are healthy and functional. The final reference in Key Stage 4 (14-16 year olds) talks of “parenting skills…to be able to make informed choices about parenting including issues around breastfeeding.”
‘Issues around breastfeeding’: there’s a phrase that doesn’t warm the cockles of your heart. Those of us who work to support new families to feed their babies can tell you something about the issues around breastfeeding. Girls are growing up not knowing how their own bodies work. They don’t know how breasts start to develop, so spend months thinking they may have cancer (because that’s the only time lumpy tender asymmetrical breasts get a mention) or they are abnormal. They are taught that breasts are to be hidden away and nipples made invisible. But then confusingly, women who show them in particular ways often seem to get more attention, especially on social media.
Girls rarely know that their breast tissue goes into their armpit. They can rarely use the word for the coloured ring of skin around the nipple (the areola) and they even less commonly know how to say it. It’s a clue this is a nationwide problem when 3 different pronunciations are all considered acceptable: arry-oh-la, a-ree-oh-la, uhrowla. They don’t know the very simplest facts about how their body might milk in the future or that breastfeeding isn’t just about making milk anyway but giving comfort, developing relationships and reducing their risk of maternal mental health problems.
The guidance claims to be about promoting healthy relationships, positive mental health and it claims to be about valuing parenthood. But there is a huge hole – and it’s breast-shaped.
If normal breast development and breastfeeding isn’t discussed in schools, we see the consequences years later when parents are expected to gain all their knowledge and confidence between finding out a baby is expected and its arrival. In 2017, The Royal College of Paediatrics and Child Health called on government to put breastfeeding into the school curriculum and that call has been ignored. It’s not about getting everyone to breastfeed. Some mums don’t want to, and some mums are unable to, but we know around 80% try to start and more than ¾ of them are let down by lack of support. We end up with a country with some of the lowest breastfeeding rates in the world as a result.
The new curriculum covers some tough realities: forced marriage, honour-based violence and FGM. Children are to be taught about the treatment of sexually transmitted infections and that alcohol and drugs can lead to risky sexual behaviour. They are taught about adopting and aborting a baby, but not feeding one. In Scotland, we can see places where breastfeeding is on the curriculum and schools can even be awarded ‘breastfeeding-friendly’ status. Why is England not joining up the dots? It’s not happening in this new guidance and it’s not happening in the science curriculum where pupils are taught about ‘the effect of the maternal lifestyle on the foetus’ but nothing about breastfeeding.
You can’t talk properly about ‘the changing adolescent body’ without saying the word ‘breast’. And if you don’t talk about breastfeeding, and instead the breast is simply a sexual organ, you are missing a huge section of the human experience.
If we don’t talk about healthy normal breasts openly, then when it DOES come time to worry about breast self-examination, the discussion is uncomfortable and embarrassing. Young women avoid doctor visits and worry alone. If we don’t talk about what breasts can do, that gap gets filled with a conversation controlled by photo-shopping, air-brushing and breasts as commercial tools to sell products. When girls and women don’t feel like they are good enough, they are encouraged to spend money to fill the void. And women who don't feel they are good enough and their bodies are deficient become mothers who don't feel their bodies are good enough.
We might imagine that retail and modelling has become more body positive but look closer. Breasts aren’t yet part of that conversation. The larger models being used have round, even, symmetrical breasts with invisible nipples. Attractive models of any size don’t sag, breasts are immoveable and symmetry is essential. We have a long way to go and it’s dangerous when we think ‘real women’ are being celebrated when parts of them are still required to fit an ideal of artificial perfection.
We need to get this right now. We need conversations in schools and we need to talk about real breasts doing real things. If we don’t get this right, those of us supporting new mums, and talking to young women about their body image, will pick up the pieces in years to come.
"The Breast Book: A puberty guide with a difference – it's the when, why and how of breasts" is available now.
Yesterday, I met a wonderful granny. I was doing a home visit and she was staying with her daughter after the arrival of a first grandchild. She had that ability to be present without being THERE all the time. She sat quietly during the consultation and sometimes appeared to be doing something else, but her ears were always on. When her daughter asked a question, she was there. She made comments at the right time and had the needed balance of encouragement and acknowledging this was hard.
At one point, the mother was looking forward to reducing bottles and moving to more breastfeeding. At the moment, she’s doing the grim routine of breastfeeding and pumping and bottle-feeding and it’s tough. She was wondering whether to retain one bottle for her husband to give her a rest and her mum reminded her that once she’s just breastfeeding, a breastfeed can feel ‘like a rest’. It’s a ‘sit down’ and a chance to take a load off. That’s often true in a society which expects mums to complete a dozen other tasks on top of looking after a newborn. And the daughter smiled. Right then, she needed that reminder things were going to get easier.
This granny had breastfed. She remembered one child being easy and one child being harder, but breastfeeding was her normal. She was relaxed around breastfeeding. She trusted it. She knew it worked. That trust for breastfeeding had seeped into the pores of her daughter. Despite her struggles, she had a confidence that her problems could be overcome, and her husband shared that confidence. I didn’t get to meet his mum.
I meet a lot of grannies. I meet the ones who make an excuse to get me into the kitchen and it turns out they weren’t a cup-of-tea pusher (as many are) but they desperately wanted a moment to talk about their own breastfeeding experience. It was decades ago – usually 30 years plus – but there’s an emotional mother in front of me and she’s not the one I was expecting to be trying to help. She might be worried about her daughter or grandchild but often she’s reflecting on her own mothering experience and she wants to share. She might want to tell me that she didn’t breastfeed at all and she needs me to know that. Sometimes she’s filled with regret: “I wish I knew someone like you when my babies were small” is a common phrase. Sometimes she’s angry about the lack of support she received. I’ve even had anger about the lack of support she received from her OWN mother.
When we support a mother, we are shaping a future grandmother too. One day she might be cornering someone in a kitchen. What will she say? Will she be filled with sadness, angry that her local breastfeeding group got cut, angry about her lack of midwife visits? And we’re making the great-grandparents too. The gaps in support now will be felt for generations. And when support is there for new mums, we are helping an infant who may not be born until the next century.
It takes a great maturity to own your own regret, appreciate what happened to you and how YOU were failed and move on to be the kind of grandparent needed for a new generation. It’s an enormous ask. And how much easier it is when a woman was able to reach her own breastfeeding goals and breastfeeding for her is a fond memory, not a space where she is feels awful.
The grannies I meet in kitchens sometimes thought all was well. They didn’t realise they DID regret anything. Feeding their infant was a very long time ago and it’s only when they are suddenly faced with seeing breastfeeding again, a surge of emotions has taken them by surprise.
Sometimes we know that surge can lead grandparents in unhelpful directions. It’s a natural instinct to want to protect yourself. It’s natural to want validation that what you did was ‘the right way’. How you chose to mother is at the heart of who you are as a woman. And after a long time, you might have forgotten that perhaps you didn’t always get to choose how you fed your baby. Was it your choice when your healthcare professional told you to only breastfeed every four hours, or not to breastfeed at night, or to keep your baby in the hospital nursery for hours at a time? You were sabotaged, but you may not have realised it at the time. You may not be conscious that trying to lead a new parent down the same path is another act of sabotage.
Now, a baby is in front of you again. This new mother is making very different choices. She’s doing this thing called ‘responsive feeding’. She’s hardly using a cot. She doesn’t seem to mind when her baby feeds again after only an hour. She’s not even that keen to put the baby down. That can all feel very alien. It can also feel like an implicit criticism of the first few weeks and months you spent as a mother. You remember being worried about babies being ‘hungry’ and wanting to fix that, but this mum hardly seems to mind why her baby might want to come to the breast. It takes a special person to take a pause and acknowledge that some of your struggles might be because of your need to validate your own mothering choices.
If you didn’t breastfeed at all, you want to believe that your children are healthy. Seeing someone who is unhappy about giving formula is a tough thing to see when it was ALL you did. Even reading leaflets and books can be challenging.
If you did breastfeed, it may have been in a very different way. Someone told you not to ‘spoil’ your baby and you believed them, and it’s feels uncomfortable to imagine you might have been misled. Perhaps your own mother or mother-in-law didn’t provide you with the support you might have wished for and now you are trying to break a cycle. It’s hard.
Thank you for being there in a world where new parents can often feel alone and isolated. I’ve seen what a difference you can make. I salute the granny who was waking through the night to sit with her daughter-in-law while she breastfed (and was in charge of nappies and winding). I salute the granny who wore a baby in a sling while a mum slept. I salute the granny who lived far away and whose gift was the time of a postnatal doula in some difficult weeks. And for some mums without partners, the granny can be the partner in raising a child.
There are grannies out there right now who are holding people together in the best way. There are the ones who lives far away who send the ‘I’m proud of you’ texts. And the ones who send the articles about breastfeeding. We don’t care that we’ve seen the article 5 times across 3 different forms of social media – we just care that you sent it.
No one expects you to know everything. It’s OK to ask questions about breastfeeding and it’s great if you do some reading. You can even do it before the baby arrives. It’s important to know that new families sometimes want some time without grandparents at the very start and that’s no reflection on you. Encourage honest conversations about how much help they need and how they want to make use of you.
Your job is to empower the new parents to be the new parents they want to be. It’s going to be different from how you made your choices. And that’s OK. Science and research show us new things. You did what you did based on the knowledge and society around you. They will do their thing too and it might all change again in a few more decades. We all do the best we can with what we know. If you say the wrong thing or blurt something out, that’s OK because no one is super human. Just give yourself space to reflect and learn and if you need help, it’s OK to ask.
If you are feeling things you weren’t expecting, you call a breastfeeding helpline too. You really can. The National Breastfeeding Helpline is 0300 100 0212. We can answer your questions about the mechanics of breastfeeding and things that are confusing you, but we can listen to feelings too. We know that mothering can bring up strong emotions. Even if the feeding was a long time ago.
The Importance of Dads and Grandmas to the Breastfeeding Mother by Wendy Jones
The Positive Breastfeeding Book by Amy Brown
The Womanly Art of Breastfeeding
And a final word to say, I'm sorry if you are a breastfeeding mum without a granny in the picture. I know that can bring all kinds of emotions. Breastfeeding counsellors might be able to offer some support to you too.
When breasts first start to grow, no one talks about it. There aren't any greetings cards that say, 'Woo Hoo! Your breasts are developing!' but you get a birthday card when you are ten and that's just about planet Earth going around the Sun ten times.
Why don't we say, 'Woo Hoo!'? Because we live in a society where we often get uncomfortable and look at the floor when it comes to talking about breasts.
They seem to be important in lots of ways but then there are these confusing rules that say when we're allowed to notice them and talk about them, and when we're not.
This book tells you all about breasts and helps you to feel confident about their arrival. They are much more than just a pair of bumps that can fit into a bra. Breasts can do amazing things that scientists are only beginning to understand. This book says, 'Woo Hoo!' and 'Wow!' and 'Isn't that amazing?' It says, 'Congratulations!' and also says, 'I know this feels a bit weird too.' Your body has looked the same for a long time and now things are changing. That can take some getting used to.
Let's get to know more about our two lifelong buddies with the WHEN, HOW and WHY of breasts.
You can pre-order The Breast Book here:
The mother above is practising responsive feeding but… brace yourself…her baby showed absolutely NO feeding cues before the breastfeed started. Wasn’t remotely interested. No cues. No ‘demand’.
And…put on a second brace…the mother looked at her watch before starting a feed. The feed started because of the clock.
How can that be?
Isn’t responsive feeding all about being ‘baby-led’?
Shouldn’t the mother be feeding in response to the baby’s cues and messages?
Isn’t responsive feeding simply another way of saying ‘feeding on demand’ but we don’t use the word ‘demand’ anymore because it sounds a bit bossy and rude?
Responsive feeding is not just a polite way of saying ‘feeding on demand’.
Let’s imagine this mum was looking at her watch because she has to go and pick her toddler up in an hour. She wanted to get a feed in before she had to leave.
Still responsive feeding.
Let’s imagine she has to leave for work. She has a Zumba class. She wants to go and have a bath and leave the baby with her partner.
Still responsive feeding.
She’s feeling engorged. She is feeling anxious. She just had a horrible phonecall and really wants a cuddle.
Still responsive feeding.
Because mums can have ‘demands’ too. They are allowed to have needs and urges and instincts and wishes. Responsive feeding is a two-way street. It’s a relationship between two people with back and forth and compromise. Sometimes one takes the lead. Sometimes the other.
It’s not a mother under the control of a teeny babygro-wearing master (or mistress).
Mothers can make decisions too. They can take the lead. They can be demanding. Sometimes their feelings might take priority for a while. Responsive feeding isn't all about a mother sacrificing her own needs. Or always putting herself second (or third or fourth).
Responsive feeding is two people meeting each other’s needs. The mother won’t get milk out of the arrangement but then the baby often isn’t looking for milk alone either. Responsive feeding meets the emotional needs of both mother and baby.
Here are some extracts from the UNICEF Baby Friendly infosheet which can be found in full here:
“Responsive breastfeeding involves a mother responding to her baby’s cues, as well as her own desire to feed her baby. Crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother.”
“She can also offer her breast to meet her own needs, for example before she goes out, before bedtime or because she wants to sit down, rest and have a cuddle with her baby.”
So, yes, sometimes a new mother might feed ‘by the clock’ and that can be OK. She might want to breastfeed for her own reasons - and that's how it's supposed to work.
This is the week when I’m supposed to be #celebratingbreastfeeding and I can’t do it.
The last fourteen years of my life have been about breastfeeding: doing it, reading about it, qualifying as a breastfeeding counsellor and then a lactation consultant, taking helpline calls, running groups, doing home visits, writing about it, getting a breastfeeding tattoo and helping to train others.
If I can’t find it in me to #celebratebreastfeeding, we’re in big trouble.
It feels dishonest to focus on celebration when I’ve lost count of all the campaigns from local families desperately trying to save their breastfeeding support service; when I get another text from someone in a hospital bed; when I hear of a mother desperately trying to find a specialist who understood the complexities of her situation and being told they were on maternity leave and no one is available.
Where I’m sitting now, there is no infant feeding coordinator in post in my London borough. Our last specialist left several years ago and was replaced by a lovely health visitor who wasn’t a breastfeeding specialist and she has now left. The last job advert read like the job of three people combined. We were going to have breastfeeding champions – health visitors and health professionals trained to give some extra support in breastfeeding. That initiative has gone away.
A couple of miles south, mums can meet a breastfeeding peer supporter in hospital and she might then come to your home. In my borough, you don’t get home visits.
You had a c-section? You have mobility problems? Shame you don’t live just one street over, isn’t it?
You want to meet someone who understands the implications of the fact you had breast implant surgery on the NHS aged 18 and can talk to you about how to maximise the amount of breastmilk your baby will receive? You want to meet someone who can assess your baby for a tongue tie (which was mentioned briefly at the hospital but the person who mentioned it wasn’t qualified to do a referral)? That sometimes seems to be more about luck than anything else.
You might only have a breastfeeding support group in term-time. You might only have a breastfeeding support group because a group of volunteers are busting a gut to run marathons (LITERALLY run marathons) to raise money to pay for a room. You might only have access to an IBCLC because one happens to volunteer in your area OR a local midwife self-funded to get specialist training in breastfeeding.
You might have NO support groups because someone actually believes a health visiting service can simply take over a breastfeeding support service. Health visitors weren’t exactly having long coffee breaks and twiddling their thumbs waiting for things to do before, you know.
I meet a midwife who has been 'told off' for spending too long trying to support a mum to breastfeed without pain. I meet another who tells me that when she looks at the list of women she has to see that day in the community, she finds herself hoping that not very many are breastfeeding – they are likely to be the ones who need a longer appointment slot and she’s not been given the time. I meet another who says she had half a day of Powerpoint slides as part of her training on breastfeeding.
I meet a doctor who says she is embarrassed when she realises how little she knew about breastfeeding before she had her own children. Actually, I’ve yet to meet a doctor who DOES NOT say that.
In 2018, Scotland published the results of their national feeding survey. Rates at six months are up. How does that compare to England, you ask? WE DON’T KNOW and we won’t know because it’s not considered important enough to find out. The last set of figures are from 2010.
100% of Scottish babies are born in UNICEF Baby Friendly accredited settings. How many in England? 58%
Can we see the English national strategy on infant feeding and talk to the English national lead on infant feeding about this? Sorry, no. Because England doesn’t have those things.
At the time of the World Cup, I need to shout LOUDLY, “COME ON ENGLAND!” and I don’t give a hoot about the football.
Don’t ask me to #celebratebreastfeeding when I just feel like crying.
What can we do?
Tell our MPs to attend the All party parliamentary group on infant feeding and inequalities. This is about supporting all babies and with Brexit approaching, formula fed babies are at risk if laws that protect the quality of formula are threatened. If your MP doesn’t think feeding babies is important, it’s time to have a word.
Write to your MP and ask them to press the government to do more about breastfeeding support, ask THEM to ask for information. Tell them about cuts in your area. If you had time to read this article, you had time to write to your MP. I think sometimes people hold off writing to their MP because they imagine it has to be a well-crafted eloquent essay. They can cope with two paragraphs where you explain that infant feeding matters to you, tell them what is happening locally and ask them to press the government to do more. Busy people, or people who don't write much, are allowed to have strong opinions too.
Fight when cuts are announced. Sign this petition: https://www.change.org/p/steven-brine-mp-uk-minister-for-public-health-and-primary-care-end-cuts-to-breastfeeding-support-stop-letting-down-millions-of-mothers
And respond to this survey about the impact of cuts: https://tinyurl.com/yars43rg
Join up the dots to the areas people are talking about. The Health and Social Care committee have highlighted the links between obesity and infant feeding: https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/882/88202.htm
Don’t forget babies in conversations about obesity.
And don’t forget feeding support in conversations about maternal mental health. It is unethical to promote breastfeeding without giving mums the resources they need to be able to reach their feeding goals. When mums want to breastfeed and they are unable to reach their goals, they are at significantly greater risk of developing mental health problems.
Be a customer of the NHS. We are grateful for the NHS and like having affection for an old aunt, it can feel a bit cruel to make complaints. We are not complaining about individual staff, we are complaining about the system that is failing them too. We need to COMPLAIN when our hospital isn’t Baby Friendly accredited. Why not? Who do we need to write to and say that isn’t acceptable? COMPLAIN when you can’t speak to a breastfeeding specialist. COMPLAIN that your neighbour gets a home visit and you don’t. COMPLAIN that your midwife didn’t have time to watch your breastfeed.
And if someone offers to bring you round a lasagne post-natally, thank them for the lasagne but ask them to stay and type out the letter to your local hospital while you dictate.
We need to STOP BEING SO ENGLISH AND MAKE A FUSS.
I have a friend who I’ve known for nearly 14 years. We got to know each other when our first children were tiny. We share photos and stories. We share a similar sense of humour. When we were bleary-eyed with baby days, we were often in touch several times in 24 hours. I know that if I were to ask her for advice and support, she wouldn’t hesitate, and she’d be honest and helpful.
But of course, because why would I be mentioning her in this article otherwise, we’ve never been in the same room. We’ve never met. She’s a friend in my pocket, in my phone and sometimes on my laptop (although that needs really big pockets).
If you’d told me twenty years ago I’d spend more time talking to people each day I hardly ever meet (and many people I will never meet) than ‘real life’ friends, I’d be very very worried.
But for many new parents in the 21st century, it is completely and utterly normal. These are the friends who live all over the world. You find them in nooks and crannies on the internet and you both recognise a kindred spirit and you hang on to each other when things seem shaky. The original forum/ group might sometimes have long gone but the connection hasn’t.
There are hundreds more online semi-mates who you bump into in your Facebook group or forum and you share information and stories. There are the faces you recognise, the admin you trust and the mothers you offer to support and encourage at 3am.
Online informal support is not going to be a substitute for real life groups and face-to-face sessions. Does anyone really need to spell that out? And I’m talking about real humans, not even ‘bots’ who read out bits of websites at you. No mother really thinks that when she has damaged nipples and she knows the latch isn’t right, Cassie from Swindon writing twenty words is the answer ahead of the lactation consultant she can call tomorrow or the trained breastfeeding counsellor at the group three miles away.
But you know what, Cassie is there at 11pm when you are praying your baby doesn’t wake up because you are in so much pain you just can’t face another feed. And she’s followed moments later by six other people who were in your shoes just a few weeks ago.
Cassie can link you to a video which has some great suggestions and she knows that this matters to you. This is a group that listens to what your goals are and when you say it’s important to you that you make breastfeeding work, they get that. They are there for the lows and the highs. Your group is a place where you can celebrate, and your team are happy for you. You can share what really matters to you with joy.
Here are 8 things that make online breastfeeding support extra great:
1. People who listen first and ask more questions.
When a mum says she’s uncomfortable, you ask more. Does she mean her nipples? Her breasts? Her back or her shoulders? What has she tried so far? What does she think might be happening? Of course, not every mum supporting online is a trained breastfeeding supporter, but some principles apply to everyone who is offering help. Great people ask for more information.
2. Knowing that your experience is not everyone’s.
It can really be tempting to talk about ‘what worked for you’ straight away but first, we start with what does that person want and need.
3. Knowing that this is a conversation with a lot of vulnerable people eavesdropping.
The person who started a post might not even be the person who benefits the most from it. They may be too shy to start a conversation or someone who searches on the group weeks and months later. They may be people who don’t know the lingo so a lot of ‘DD’ and ‘DS’ and even the occasional ‘IYSWIM’ and ‘AFAIK’ can be off-putting and isolating.
4. Knowing what you don’t know.
I have been known to literally cheer when I see someone saying, “I’m not sure” and signposting somewhere else. Three cheers for the person who says, “there could be an underlying issue we can’t identify here so why don’t you talk to X”. And a wet raspberry to the person who just says, “pump more,” or “It sounds like you definitely have thrush.” You don’t know someone’s mental health or their physical health. You don’t know someone’s support network. You may not be aware of something that someone trained is aware of.
Who do you refer to? With any medication question, it can be the drugs in breastmilk service run by the Breastfeeding Network. https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/. The answers might be on the drug factsheets or you can email or send a Facebook message.
It might be someone needs a breastfeeding support group. They can be found through the ABM page, the Breastfeeding Network page or simply by googling someone’s town and ‘breastfeeding’.
The National Helplines can be invaluable. Their volunteers will be trained to ask the right questions.
National Breastfeeding Helpline – 0300 100 0212
Association of Breastfeeding Mothers – 0300 330 5453
La Leche League – 0345 120 2918
National Childbirth Trust (NCT) – 0300 330 0700
They might need a lactation consultant (lcgb.org) or a private tongue tie practitioner (www.tongue-tie.org.uk).
They might need to go back to their GP or their midwife or their health visitor.
5. Reading what other people have already said.
Hooray, for the person who says, “I can see someone earlier said, Y and I just want to add Z” and wet raspberry to the person who just repeats what’s been said an hour earlier. If you’ve got time to read the original person’s question, you’ve got time to read at least some of the comments already there. You might be missing a big twist. Perhaps someone earlier asked some questions and learnt something crucial and your contribution might not be reinforcing what is helpful. Sometimes it’s better to step away and write when you do have time to reflect more carefully. It’s better to say, “I’m sorry I don’t have time to read all the comments, but I just wanted to say that I’m sorry you are having a hard time,” than to post a suggestion without reading a chunk of conversation and missing something important. Yes, it might take time to load comments on your phone. Still better to wait and brownie points for the people who take the extra few moments to find out what’s going on, so they can offer proper informed support.
6. People who are kind.
They know that the first job is help someone to feel supported. They might not agree with an earlier comment, but they manage the situation with an emotional intelligence that means the original poster doesn’t feel like she’s in the middle of a squabble at a time when she feels vulnerable. They know that new parents get stressed and people can misread tone on the internet and they give people the benefit of the doubt and ask before making assumptions. They are kind enough to give of themselves and try and help.
7. Fab admin.
Three cheers and then another three cheers for the admin of Facebook groups and online forums. They are the people who know when it’s time for a conversation to end. They know when to gently raise an eyebrow when the mother worrying about milk supply is told to eat lactation cookies and drink lots of water. They know when to link to the right article and signpost to real life when someone else is simply saying, ‘not to worry’ about a baby not putting on weight as we might hope. There’s a team that look after each other. No admin gets to the point of feeling burnt out and there’s a very careful rota system. The reason why the breastfeeding charities don’t tend to run their own online support groups is because the burn-out is a huge problem and when a volunteer who’s been trained for sometimes two years plus burns out, that’s a huge loss. Being an admin is a big responsibility. Once you are known to represent a particular organisation, it becomes an actual legal responsibility. Even without that, you are taking on responsibility for the health of the most vulnerable. You need a team who look after each other. Great admin makes a safe space. The best admin knows they might have more to learn because ANYONE worthwhile in this world knows they have more to learn. Without them, thousands and thousands of new parents wouldn’t get the help they need. Thank you, online admin stars.
8. The ‘specialised’ groups.
The one for breastfeeding twins and triplets, the one about relactation, the one with people breastfeeding older nurslings, the one that contains your team who get exactly what you are going through and when you found them you felt like you were home. Yay for the people that thought to start them and yay for the people who hang around even after their own experience ends to support those who might be struggling.
Online breastfeeding support can be magic. It can inform us and encourage us and direct us to the right information. It can connect people and be the ‘village’ we’re told so often we need to raise a child. In a local breastfeeding support group, what would be chances have been that you would have found someone with this shared experience?
Friends in our pocket can help us get is through the day. Just raise an eyebrow at anyone who claims we can do without the support that doesn’t fit in your pocket too. Families need it all.
A dad at my breastfeeding support group this week had a bit of an epiphany. ‘It’s never felt like this before,’ his wife had said. We’d spent just 3 or 4 minutes together. I’d mentioned one or two things about the way she was holding her baby. It was enough to make all the difference.
Just like in golf, he noted, with a tiny change to swing and position the game had been transformed.
As a lactation consultant, you study for hours and hours and pages and pages and pages. You know lots of things you may not talk about from month to month. But there are twenty or so things you say nearly every day.
So many mums have their experience transformed by a tweak. They are sore, dreading each feed, wondering how things will ever change and one comment – that may not even be 20 words long – can make all that go away in an instant.
It’s one reason why even a rushed midwife or GP can turn breastfeeding around with the right training, even if they don’t always have the time to devote to a long support session.
Here are a few of my favourite tweak considerations:
1. Get a glass of water. Take a drink. Notice how you tip your head back and your chin comes away from your chest? Now try to take a drink with your chin pointing down towards your chest. Not so easy. Try and do that every time you drink, and I think you’ll find you take less, give up sooner that you might otherwise and probably get a bit windy. So, tweak number one is hold your baby in a position where they can lift their chin away from their chest. If you are using a cradle hold or a cross-cradle hold, that means you might need to have them further away from the feeding breast’s armpit and slid more across towards the non-feeding breast. We talk about ‘nose to nipple’ because that’s encouraging the baby to reach towards the nipple with their head tilted back. If you are using a rugby hold, super important the baby isn’t too far forward so they end up curling around the breast with their chin hunched towards their chest.
2. Don’t hold the baby’s head too high on the back of their head or push the baby’s head towards the breast. Babies are clever at protecting their breathing (why we don’t need to press our fingers into the breast near baby’s nose). And nature has given them a reflex which means when someone pushes on their head, they’ll be very unhappy about attaching in case they can’t rescue themselves when breathing becomes restricted. They may even push back and shallow the latch and sometimes even refuse to feed entirely. So, support baby’s head by holding around the base of the skull – supporting around their shoulders and chin and ears area – but no higher. Imagine Elvis towards the end of his career in Las Vegas with those diamond encrusted collars. You’re holding your baby’s Elvis collar and no higher. And even then, as gently as possible. Just enough to support baby’s head without being too bossy or firm. You might even be using a position where this isn’t a risk at all – you might be lying down or using a reclined position where your hand is nowhere near baby’s head.
3. Beware the cushion myth. I am not kidding when I say that most people I meet using breastfeeding cushions are using them in a way that makes their life harder for themselves. The gap between your lap and the natural fall of your breast is probably very different from your mate’s. It’s going to depend on the length of your torso, the size of your breast, the way your breasts fall, the height of your lap which varies with your chair. It’s also going to depend on the shape of your baby. So how on God’s green Earth did we all get the message that the same size of breastfeeding pillow fits everyone?
Again and again and again, taller mums are slumping forward and hunching over their baby lying on their cushion. ‘This cushion must be right. I just have to contort myself to get to it!’
And shorter women also think that the cushion is surely the answer, so they put baby on the cushion and umm, there’s no space between their breast and the cushion for baby to fit. They often end up lifting their breast so baby can fit underneath. They might then have to hold their breast throughout the entire feed, compressing ducts and causing hand pain and usually not holding the breast in the same position the whole way through a feed so things wobble around.
Or folks might put the baby on the cushion and baby is a few centimetres too far away from them with sometimes not even the chin and chest making contact with mum at all.
Cushions can be handy to support mum’s arms, but it doesn’t normally work that the baby can’t be held by mum and is entirely on the cushion.
What often works even better is no pillow at all and mum leaning back a bit. Check out: http://www.mothering.com/articles/natural-breastfeeding/
4. Baby needs to be clooose. If you can see the buttons down the front of baby’s sleep suit, they are probably too far away. If baby’s arm is trapped between you, they are being pushed too far away. If there’s a big blob of your clothing and a breast pad between you, they are probably too far away. I once supported a mum who found night time feeds much more painful. She was sitting in the same chair to feed as she did in the day and was using exactly the same position but at night it was pinchy and uncomfortable. It turns out the difference was that the baby was wearing a sleeping bag at night. Just a few extra millimetres of padding meant that baby’s chest and chin was a little bit further away from mum’s body and the nipple wasn’t going back far enough into baby’s mouth. Baby’s chin needs to be close into the breast. It’s not going to work if the baby’s chin isn’t touching the breast at all. And the chin can’t touch if the chest is too far away.
It’s common for a mum to say, “Wow it doesn’t hurt anymore!” followed by “I haven’t been having them close enough!”
5. Mums are fiddling around and ‘checking the latch’. It’s completely understandable that when someone tells you the baby’s mouth should be a certain way and the bottom lip should be flanged out like a fish lip, you think you are supposed to check! But the minute you push your baby’s cheek out of the way and have a bit of a rummage, you’ve made some adjustments. Better to go with a look at the baby as they approach the breast and the mouthful you saw them take and how it feels. And how the nipple looks when it comes out of baby’s mouth (might be elongated but shouldn’t be squashed and flattened at the end.) If the baby is close enough, you usually can’t see the lips at all. The rounded part of baby’s cheek is in contact with the breast and the lips are hidden.
6. And while we are talking about lips, the top lip doesn’t need to flange out and do the fish lip thing. It can rest in a neutral position. An excessively flanged top lip can even be the sign of a shallow latch. I’ve met several mums who have been told that the top lip should stick out and even flip it out themselves to make that happen. Curled in isn’t ideal but it doesn’t need to flip out.
7. Babies are sinking. Mums might start with baby on a squishy pillow and as the feed goes on, gravity does evil things and the baby starts to sink. The movement might be imperceptible but it’s enough to pull the baby away from the breast. That pregnancy pillow filled with beans that the manufacturers claimed was super for breastfeeding? Meh. If it’s bean-filled, it’s likely to sink. That favourite feather filled bed pillow? Going to sink. Holding all the weight of your baby on your arms and hands and sitting bolt upright? You are going to sink. You are not designed to hold the weight of your baby in that position for minutes and minutes throughout the day. It’s a big clue if you finish a feed rubbing your wrist and thinking, ‘phew, glad that’s over!’ Gravity is your enemy. You need to find a position which you can sustain. That might be the right cushion for you (or more than one) or again, it might be about leaning back. Babies also latch better when they are anchored. If they feel themselves slipping, they may even clamp down and things can get even more sore.
8. What’s the bottom cheek doing? Not many of us have nipples that come out from our body at precise right angles. So why do so many of us feed a baby as if that’s true? The baby is precisely ‘tummy to mummy’ and lying on a breastfeeding cushion as if our nipples are pointing directly in front of us. In fact, most women have nipples that point slightly down (or off to one side and down). But we put baby into the ‘right angle’ position anyway. What ends up happening is that the top cheek (which mum can see in a cross-cradle or cradle position) is nice and close to the breast and rounded. However the bottom cheek can be centimetres away from mum’s body with an unhelpful gap for air to get in and a shallowed latch. Get someone to check that the bottom cheek is touching the breast too. Look at your natural body shape. Your baby may need to look up towards your shoulder rather than at the back of the chair. You may be able to see both of their eyes.
9. Ear/ Shoulder/ hip in alignment. Get that glass of water again. Twist your neck and try to take a drink. It’s rrrreally hard. And if what you were drinking was gradually getting thicker and fattier, again, you’re likely to be taking in air and giving up sooner than you might. Baby can’t lie on their back and twist their neck towards you to come to the breast. We want the ear and shoulder and hip to all be pointing in the same direction. Even a baby with a twisted torso and the twist is around the hips can run into problems.
10. Look at your body. Look, that mum over there in Costa seems to be able to drink her coffee (yes, you can drink coffee) and is just supporting her baby on one arm! How the heck! Can I do that? You know how hairdressers’ clients turn up to their appointments with a celebrity photo and say, ‘make me look like that!’ That sometimes happens in breastfeeding too. ‘Can I hold my baby like that mum I saw?’
Sometimes the answer is yes and sometimes it’s no. Your humerus is the bone that goes between your shoulder and your elbow. Sometimes your humerus bone and the height of your breast isn’t ideal for particular positions. Long humerus and high firm breast? You may not be able to do the cradle hold. I mean seriously – you may NEVER be able to do the cradle hold. The baby will be too low. Short humerus and long low breast? You may not be able to do the position that that woman in Costa can do and drink coffee. You might always need a hand to support the breast if you want to do the cradle hold.
It’s not all about the pictures in that breastfeeding book or what your mates are able to do. It’s about the shape of your body and the shape of your baby. Do you need to factor in wheelchair arms? Do you need to think about how your breast texture changes in the day? It’s all very individual. Trying to make it work like everyone else does it can be unhelpful - which is why getting face-to-face help tailored to you can be so useful.
11. Give the baby more space for their tongue on the breast. You may have heard people talk about baby getting more of a mouthful of breast below the nipple than above. Or seeing some areola above the top lip and less (or none) below the bottom. If the baby has more space for their tongue on the breast, they have a chance of scooping more breast into their mouth and the latch being deeper. When the nipple is going in, picture it pointing towards the roof of baby’s mouth rather than pointing down the back of their throat. Even just a little bit of re-angling can make things easier.
12. Don’t make your baby eat cotton. Breastfeeding clothes also assume we’re all the same. If you find them a faff – as you pull open a teeny slit to find your nipple hidden in there somewhere – I’m pretty sure your baby does too. If they ping back so the baby’s nose and cheek comes back into contact with fabric again, maybe rethink. I’ve even seen babies with fabric in their mouths with a look of resignation that says, “This is the best I’m going to get”. Cheap vest tops you can pull out of the way are very sensible. You can layer more than one so different bits are covered. And a bulldog clip is useful for securing fabric (not your chin holding your clothing and preventing it from flopping down onto baby’s face).
As I say, some of that really isn’t complicated. It’s what we talk through on the breastfeeding helplines and what we point out every day in breastfeeding support groups. While at the same time NOT saying that it’s ‘normal’ to be pain at 10 days or your nipples just need to get used to things. If you feel breastfeeding is just all too hard, remember you could be seconds away from fixing things.
Let’s imagine you are breastfeeding your toddler and you discover you’re pregnant. It’s a much wanted pregnancy but perhaps you weren’t expecting that positive test quite so quickly. And now here you are, pregnancy test still drying, teeny tiny new person inside you and less teeny person on the outside, very much still in love with breastfeeding.
By still feeding your toddler, you’ve already been up against it in terms of what most modern cultures find comfortable and acceptable. Now you’re ticking the box for another misunderstood area of breastfeeding: one full of myths and nonsense and one lots of uneducated people claim to be experts about.
A useful starting point is finding a group online of mothers who have breastfed through pregnancy and beyond. That can be reassuring and immensely helpful but it’s worth remembering that every woman’s experience is different and it’s very hard to make predictions about how things will go for you.
I’m going to guess that when many people are looking at the drying pregnancy test, their thoughts shift to the consequences for their current nursling. Then soon, you wonder about the baby-to-be. Is breastfeeding during pregnancy ‘safe’?
What does the research say?
Let’s look at this study from 2012: A comparative study of breastfeeding during pregnancy: impact on maternal and newborn outcomes. Madarshahian F, Hassanabadi M. The study looked at 320 women in Iran, some breastfed during pregnancy and some did not. It showed that, “Results found no significant difference in full-term or non-full-term births rates and mean newborn birth weight between the two groups. We further found no significant difference between full-term or non-full-term births and mean newborn birth weight for those who continued and discontinued breastfeeding during pregnancy in the overlap group.”
So, breastfeeding during pregnancy didn’t ‘take nutrition away from the baby’ and it did not cause prematurity.
Another study of 57 Californian women from 1993: Breastfeeding during pregnancy. Moscone SR, Moore MJ. Just under half continued to breastfeed through pregnancy and after the new baby arrived. The new babies were healthy and appropriately sized.
However, it’s not all clearly positive. Another research study on 133 women in Peru found a link between breastfeeding through pregnancy and 125g on average less weight gain for the new baby in the first month. (Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during early infancy. Marquis GS, Penny ME, Diaz JM, Marín RM. 2002)
Another study looked at 540 women in Egypt with sub-standard nutrition. Effect of pregnancy-lactation overlap on the current pregnancy outcome in women with substandard nutrition: a prospective cohort study. Shaaban OM, Abbas AM, Abdel Hafiz HA, Abdelrahman AS, Rashwan M, Othman ER (2015). This was not all positive news with increased risk of maternal anaemia and issues with infant growth. BUT there was NOT an increase in miscarriage risk when women breastfed through pregnancy.
How’s your nutrition and how are your iron levels? If you are a mother with access to good nutrition, it appears you have less reason to be concerned.
Does breastfeeding trigger early labour? Even for those women who were struggling with other issues, it doesn’t appear so.
Hilary Flower is the go-to person on the subject of breastfeeding during pregnancy. Her book, “Adventures in Tandem Nursing” is considered the bible on this subject. It was first written in 2003 and is now out-of-print but a second edition is currently being worked on. Her focus was on bringing the facts to pregnant mothers and she looked at this idea of triggering contractions or early labour in detail. She reminds us that we need oxytocin to trigger a milk ejection reflex (the letdown reflex) and this is also the hormone that can trigger uterine contractions. However, this doesn’t mean that breastfeeding in pregnancy triggers risky contractions and there are several safeguards in place. We need hormone receptor sites to exist before hormones get acted on by the uterus and they remain small in number until around 38 weeks of pregnancy. And even the hormone receptors that are in place can’t really do their job of causing contractions as there are oxytocin blockers in place like progesterone (made by the placenta) and proteins missing which would act as special agents to help the oxytocin do their job. Triple protection! So, oxytocin can carry on doing its breastfeeding jobs while baby remains protected in the uterus.
I think we can say science is on our side. Which makes sense when you think that throughout history women have been breastfeeding older babies and having sex and getting pregnant.
Do you know anything about the history of pregnancy testing? Today, we might know we are pregnant days after conception. For generations, it was based on guess work, someone examining your urine’s appearance and something about rabbits (early 20th century pregnancy tests involved injecting urine into a rabbit and observing a change in their ovaries). A lot of breastfeeding women couldn’t rely on whether they had missed a period as periods may only just be settling in or may not have even appeared yet. Some breastfeeding mums get pregnant without yet having a period. They ‘catch the first egg’. Then they go and see their doctor and the doctor brings out the chart that predicts due date based on last menstrual period, “errr…2015?”
Nature isn’t daft. If breastfeeding during pregnancy was hazardous, I doubt you nor I would be here. Hilary Flower mentions that if you have a high-risk pregnancy, you should talk to your health care providers about your specific situation but if you are safe to continue sexual intercourse, breastfeeding is very very likely to be fine too.
Science might say that breastfeeding during pregnancy is safe but that doesn’t mean you have to do it, or that it’s super easy for everyone. There is a wide range of experience and you need to reflect on what feels right for you.
The age of your current nursling might be a factor in your decision. If they are 7 months, you might feel differently than if they were 4 years old and you were getting a bit tired of breastfeeding a plastic truck several times a day.
If your baby is 7 months, or at any age where milk is still a significant proportion of their nutrition, you’ll need to do some thinking. It’s likely they will need an alternative source of milk (still doesn’t mean breastfeeding needs to end). Most women who are breastfeeding when they are pregnant do notice a decrease in milk supply – often a very significant one. This can start as early as the first few weeks after that positive pregnancy test. Whatever you do, your body will be resetting in its lactation story and you will go back to making colostrum during your pregnancy. It happens at different times and some mums might go through a period of feeling like they have virtually nothing and their child is ‘dry nursing’ before colostrum then appears and quantities seem to increase again.
Nurslings behave differently during the changes of pregnancy. Some self-wean as the quantities drop. Some self-wean when things seem to taste a bit different. Some care not a jot that changes are happening and would carry on breastfeeding whatever was coming out or if nothing was. Word of warning: colostrum has a laxative effect. That’s one of the reasons it’s so great for newborns as it helps them to pass meconium. Potty training a toddler? Brace yourself.
What else can you expect? For some women, not much else. Pregnant and breastfeeding felt a lot like not pregnant and breastfeeding. You’ve just got to worry about the bump being in the way towards the end. (This was my experience).
Other women struggle with sore nipples from increased sensitivity that probably has something to do with hormonal changes and sometimes aversion to breastfeeding can be a problem.
The reduction in milk supply can also be upsetting for some. It can come at a time when we might already have mixed feelings about giving birth to another child. We know what positives a new sibling can bring for your toddler but there’s sometimes a feeling of loss or even guilt as we’re concerned how their life is going to change – especially in the first few months. And when milk seems to be going too – that can feel doubly hard. Unfortunately, there isn’t much you can do to increase milk supply in pregnancy when changes are starting. All the usual stuff doesn’t work: pumping, herbs, just feeding more frequently. Many herbs that we might consider when we want to increase production are not thought to be safe in pregnancy. It appears that milk storage is affected for almost all women (only a small minority don’t feel their supply has diminished). You might want to consider using a supplementary feeding system at the breast, so baby can remain attached and get other milk through a lightweight tube.
It’s important to remember though (and this is engraved on the heart of many of us in breastfeeding support) that BREASTFEEDING IS NOT JUST ABOUT MILK. Your little bloke with the plastic truck might not care a jot if supply diminished and milk tastes different because this is only partially about milk. It’s also about connecting to you, relaxation, safety and contentment. That big world out there is only getting bigger and breastfeeding is home.
If you are happy to continue with that, breastfeeding is still working.
You might also be wondering what life is going to be like when the new baby arrives. How does breastfeeding work when there is a newborn and a toddler? Pretty much like it did the last time there was a newborn – nature gets on with it. While breastfeeding during pregnancy doesn’t ‘use up’ colostrum, during in the first few days after the birth, it’s sensible to let the newborn do their thing first before the older nursling gets a turn. And once your mature milk transitions, you can make decisions based on how your newborn’s nappies and weight gain are getting on. Sometimes there is talk of restricting a baby to one breast and a toddler to another. Most lactation consultants agree that’s not sensible. Ideally you want the newborn to have the option of both and continue to have the option of both fully lactating as their breastfeeding experience continues. Toddlers feeding after newborns are very effective at helping a milk supply to develop and tipping into oversupply is more of a worry than running out of milk. A toddler is also fabulous at relieving engorgement in the early days post-partum. Flashback to my 3-year-old son announcing proudly to his grandmother (not entirely on board with natural term breastfeeding) that he ‘helped mummy because her milkies were really full’!
Does the toddler feel jealous of the baby having ‘their milk’? I have yet to meet a mother who feels that’s been a problem. In fact, many feel that it can help in the arrival of a new member of the family. Toddlers are likely to need some extra support, but breastfeeding is still there for them. The thing that has always provided comfort and reassurance. And good news! It’s changing back to regular milk and there’s lots more of it! What might not be sensible is weaning a toddler in the last few weeks of pregnancy so if you are thinking tandem breastfeeding really isn’t for you, it might be wiser to wean sooner rather than just prior to baby arriving. If that’s you, I wrote an article on weaning an older child which you might find helpful:
It sometimes happens that an older child who hasn’t breastfed for a while asks to do so again when a new baby is on the scene. That might be because they weren’t a fan of the colostrum. Or there might be some other things going on in their head. Are they ‘testing’ whether they still get to be your baby? Are they just curious? Some resume breastfeeding at this point. Some are happy to have a taste of expressed milk in a cup. Some ask and run away giggling and don’t mention it again. There’s no right or wrong answer on how to deal with this but ideally, we’re looking for ways to minimise rejection and any refusal is done so as gently as possible.
Still think it’s a bit hippy and ‘risky’? This is the American Academy of Family Physicians (folks on the opposite end of the spectrum from hippy and risky):
“Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman’s personal decision. If the child is younger than two years, the child is at increased risk of illness if weaned.
Breastfeeding the nursing child during pregnancy and after delivery of the next child (tandem nursing) may help provide a smooth transition psychologically for the older child.”
We can’t guarantee it’s all smooth but breastfeeding through pregnancy and beyond is something mothers have been doing for millennia and there’s very little to fear and lots to embrace. Those of us who do it are often those who have taken the path of child-led weaning and it instinctively feels right to let the nursling make the call. But you’ll make the decision that’s right for you.